LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA'. 



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MANUAL 



OF 



NERVOUS DISEASES 



AN INTRODUCTION TO 



MEDICAL ELECTRICITY. 



BY 



A. B. AKNOLD, M. D. 



Prof, of Diseases of the Nervous System and Clinical Medicine, 
College of Physicians and Surgeons, Baltimore, Md. 



iL. IS 



y 



WITH ILLUSTRATIONS. 




NEW YORK : 
J. H. VAIL & COMPANY 

1885. 






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h 



■O 



Entered according to Act of Congress, in the year 1885, by A. B. Arnold, 
in the Office of the Librarian of Congress, at Washington, D. C. 



Press of 
Isaac Friedenwai.d, Baltimore. 



PREFACE. 



A long experience in clinical teaching has convinced me that the 
standard works on diseases of the nervous system are little suited to 
the wants of the beginner, who is not prepared to profit by the study 
of elaborate treatises. This conviction prompted the preparation of 
the present work, in which I have endeavored to present in a concise 
manner the established facts and current theories relating to nervous 
affections. To this end, in addition to the matter furnished by my 
own observations, I have freely used the most approved contributions 
to medical literature that deal with the subjects in hand. 

The introductory chapter on the anatomy and physiology of the 
nervous system is particularly intended to draw the student's 
attention to the recent and important accessions to neurology. 
Much care has been bestowed on the subject of general symptoma- 
tology. A synopsis of the medical use of electricity seems to me 
not inappropriate in an elementary work that treats of a class of 
diseases in which this therapeutical agent is almost exclusively 
employed. Eespecting the order in which the separate diseases are 
discussed, I preferred to retain the plan adopted in the annual 
course of lectures which I deliver in the College of Physicians and 
Surgeons, and which form the groundwork of this book. 

A. B. ARNOLD. 

168 W. Fayette Street, 
Jan. 12, 1885. 



CONTENTS 



CHAPTER I. 

The Anatomy and Physiology of the Nervous System. 

PAGE 

1. The Nerves, 1 

2. The Spinal Cord, 3 

3. The Brain, 9 

4. The Localization of the Functions of the Brain, 13 

5. The Arterial Circulation of the Brain 17 



CHAPTER II. 
General Symptomatology of Nervous Diseases. 

1. Sensory Disturbances, 21 

2. Motor Disturbances, 23 

3. Cephalic Symptoms, . . . .24 

4. Pupillary Changes, 26 

CHAPTER III. 
Medical Electricity, .31 

CHAPTER IV. 
Special Pathology and Therapeutics. 

1. Neuralgia, 43 

2. Hemicrania, 47 

3. Angina Pectoris, 52 

4. Headache, 54 

CHAPTER V. 
Peripheral Paralysis. 

1. Lead Palsy, 57 

2. Acute and Chronic Neuritis, . . . . . . . . .59 

3. Paralysis of Ocular Muscles,' 60 

4. Facial Paralysis, . . .60 

5. Laryngeal Paralysis, 63 

6. Paralysis of different Muscles, 64 



VI CONTENTS. 

CHAPTER VI. 
Spasmodic and Allied Affections. 

1. Spasms of the Muscles of the Face, Neck and Trunk, . . . .67 

2. (Writer's Cramp), . 69 

3. (Paralysis Agitans), 71 

CHAPTER VII. 

t 

Diseases of the Membranes of the Spinal Cord. 

1. Hyperaemia and Hemorrhage of the Spinal Membranes, . . 73 

2. Spinal Meningitis, . . . 73 

3. Epidemic Cerebro-Spinal Meningitis, 75 

CHAPTER VIII. 
Diseases of the Spinal Cord. 

1. Acute Myelitis, 79 

2. Chronic Myelitis, 83 

3. Varieties of Paraplegia, 84 

4. Acute Ascending Paralysis, 86 

5. Infantile Spinal Paralysis, . . . . . . . .86 

CHAPTER IX. 
Systemic Diseases of the Spinal Cord. 

1. Progressive Loco-motor Ataxy, 89 

2. Multiple Sclerosis of the Brain and Spinal Cord, 94 

3. Spasmodic Spinal Paralysis, .97 

4. Progressive Muscular Atrophy, 98 

5. Pseudo-Hypertrophy of Muscles, 101 

CHAPTER X. 
Diseases of the Membranes of the Brain. 

1. Pachymeningitis, 103 

2. Simple Acute Meningitis, 103 

3. Tubercular Meningitis, . . . 107 

4. Inflammation of the Sinuses of the Dura Mater, Ill 

CHAPTER XI. 
Diseases of the Brain. 

1. Cerebral Hyperaemia, . . . . 112 

2. Cerebral Anaemia, 113 

3. Cerebral Hemorrhage, 115 



CONTENTS. Vll 

4. Softening of the Brain, 122 

5. Tumors of the Brain, 124 

6. Cerebral Abscess, 127 

7. Cerebral Syphilis, 128 

8. Bulbar Paralysis, 132 

CHAPTER XII. 

The Classical Neuroses. 

1. Epilepsy, 136 

2. Chorea, 146 

CHAPTER XIII. 

1. Hysteria, 150 

2. Spinal Irritation, 155 

3. Neurasthenia, 158 

4. Hypochondriasis, 160 

5. The General Paralysis of the Insane, 162 

Index, 167 



CHAPTER I. 

THE ANATOMY AND PHYSIOLOGY OF THE 
NERVOUS SYSTEM. 

The Structural Elements of a nerve consist of longitudinal white 
fibres, held together by a dense fibrous sheath (perineurium), which 
unites them into round or flattened cords. Each nerve fibre is sepa- 
rated from the rest by a thin sheath (neurilemma), and presents the 
appearance of a tube which contains medullary matter. In its centre 
there is a fine string, called the axis cylinder, which appears to be the 
essential element of a nerve fibre. 

The Chemical Composition of nerve tissue is not well understood. 
The axis cylinder is probably an albuminoid substance ; its medullary 
portion gives the reaction of fat. 

The Non-medullated or Pale Fibres. These are of two kinds. 
Those presenting a non-medullated appearance throughout their 
whole course, as first pointed out by Remak, occur in the sympa- 
thetic and olfactory nerves. They are of a grey color, homogeneous, 
and flattened. The other variety is found in many nerves at their 
peripheral expansion, where they are deprived of the medullary 
substance and appear as naked axis cylinders. Although the 
nerve fibres are united into cords like threads in a skein of silk, they 
nowhere in their course anastomose or divide into branches. 

Afferent and Efferent Nerves. A nerve which transmits an im- 
pression from the periphery to a nervous center is called an afferent 
or centripetal nerve, and one which carries an impulse in the oppo- 
site direction is called an efferent or centrifugal nerve. There is no 
specific difference between these two orders of nerves ; the difference 
in function depends upon the character of the end-organ with which 
the several nerves are connected. A sensory nerve is obviously 
afferent or centripetal, for it conveys the stimulus from a peripheral 
to a central organ, where the stimulus may either be transformed 
into a conscious sensation (perception), or, stopping short of that, 



2 MANUAL OF NERVOUS DISEASES. 

excite a reflex center and initiate muscular movement. A motor 
nerve is always efferent, for it carries the impulse in a centrifugal 
direction, i. e. from a nervous center to a muscular organ, which 
responds by a contraction. 

The Rapidity of Transmission of a sensory impression or of a 
motor impulse has been variously stated. It appears that the rate 
of conduction for both kinds of nerves is about thirty-four metres 
in a second. 

Nerves of Common Sensation. Anatomical proofs are wanting 
that the different qualities of sensibility (tactile, painful, thermic 
sensations) depend upon distinct sets of sensory nerves. Pfluger 
maintains that the tactile and painful sensations are transmitted 
through the spinal cord by different channels. 

Nerves of Special Sensation. Those cranial nerves which are con- 
nected with peripheral organs convey only the special impressions 
for which these structures are adapted. The retina is only excited 
by luminous rays; the basilar membrane of the cochlea of the ear by 
vibrations of the air ; the olfactory epithelium by odorous particles. 
Nerves of special sensation, when under the influence of mechanical, 
chemical or electric excitation, invariably react in correspondence 
with the functions of the organs to which they are related. Irrita- 
tion of the optic nerve is always followed by some visual symptom ; 
that of the auditory by the perception of sound. 

The Muscular Sense. Physiological considerations point to the 
existence of a muscular sense, which may be supposed to depend 
upon sensitive nerves intimately connected with muscular fibres. 
To carry out voluntary motor impulses, such as standing, walking, 
swimming, it is necessary that the mind be informed by definite 
sensations of the degree of effort which is required. Every volun- 
tary strain or contraction of the muscles is attended by a sensation 
corresponding to the amount of energy which is put forth. It may 
therefore be said that the muscular sense has an educating influence. 

The Nerve Cells. The structural elements of nerve cells or gan- 
glion cells consist of a soft translucent substance and pigment 
granules, forming irregular or angular-shaped bodies, which send 
out from their circumference finely branched processes. According 
to the number of these processes, a cell is said to be uni-, bi- or mul- 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 3 

tipolar. Each cell contains a round and well-defined nucleus in its 
interior, and, within this, one or more nucleoli. Nerve cells abound 
in the grey substance of the brain, the spinal cord, and in the sym- 
pathetic. They are also frequently found in the peripheral expan- 
sion of nerves. 

The Functions of Nerve Cells. Nerve cells are the centers of nerve 
action wherever found in the animal organism ; and since the brain 
and spinal cord are largely made up of such cells, these structures 
are considered the main centers of the nervous apparatus. The func- 
tional activities of ihe different nerve centers may be thus sum- 
marized : 1. Automatic Action. A nerve center excites a centrifugal 
impulse independent of an external influence. The respiratory 
movements and cardiac contractions are examples of automatic 
action. 2. Reflex Action. An impulse coming from a centripetal 
nerve produces an active state in the nervous center with which it is 
connected. This excites a motor or another kind of impulse which 
is conducted by a centrifugal nerve. The spinal cord may be consid- 
ered a system of such reflex centers. 3. Psychical Phenomena. The 
active state of certain nerve centers is intimately related to mental 
manifestations — intelligence, volition, etc. These centers are also 
called "perceptive centers," and are located in the grey cortical 
substance of the brain. 

The Spinal Cord. 

The spinal cord is closely invested by the pia mater, and only 
loosely enveloped by the dura mater. The latter membrane is sep- 
arated from the vertebral canal by venous plexus and areolar tissue; 
and from the pia mater by the arachnoid. Within the meshes of the 
arachnoid there is a fluid named the cerebro-spinal fluid. From the 
surface of the cord, the roots of the anterior and posterior spinal 
nerves emerge and pass out through the intervertebral foramina. 

Two well-marked fissures run in a longitudinal direction along 
the cord, one in front and the other behind. They are named, 
respectively, the anterior median fissure and the posterior median 
fissure. 

A transverse section of the cord presents two crescent-shaped 
masses occupying each lateral half, with their bases joined together 
in the middle by the grey or posterior commissure. This commis- 
sure is separated by a layer of white matter from the bottom of the 



4 MANUAL OF NERVOUS DISEASES. 

anterior fissure. Within the grey commissure the central canal runs 
through the whole length of the cord. 

The prolongation of each crescentric body is named, according to 
its situation, the anterior cornu or horn, and the posterior cornu or 
horn; the anterior being more massive and shorter, the posterior 
more slender and longer. The narrower portion of the posterior 
horn near its continuation with the central grey substance, is called 
the cervix cornu ; its enlargement behind is called the caput cornu 
posterioris. The grey matter at the tip of the caput cornu is distin- 
guished as the gelatinous substance of Rolando. Another peculiarity 
of the grey matter is noticeable near the junction of the posterior 
horns where it presents a vesicular appearance. This is called 
Clarke's column. 

The two anterior columns divided by the anterior median fissure 
are situated between the two anterior horns ; the lateral columns, 
one on each side, occupy the space between the anterior and posterior 
horns ; and the posterior columns, marked off by the posterior median 
fissure, run between the two posterior horns. A superficial furrow 
is recognized along each posterior column. The part on its inner 
side, principally in the cervical segment of the cord, is known as 
Goll's column. 

The Ganglionic Nerve Cells of the Grey Substance are divisible into 
several groups according to their size and locality. Large cells pre- 
ponderate in the cervical and lumbar enlargements, and in the 
anterior horns. Those of a medium size are mostly found in Clarke's 
column. The small cells prevail in the posterior horns and in the 
substance of Rolando ; but large and small cells are found through- 
out both horns. Bundles of medullated nerve fibres run in every 
direction between these cellular elements. 

The Connective Tissue. — Neuroglia. 

The nerve elements of the spinal cord are closely united by an 
interstitial tissue throughout every part of the white and grey sub- 
stances. This fine tissue or neuroglia contains nuclei and stellated 
bodies, resembling the cells of common connective tissue. They 
sometimes increase in number and size under pathological influences. 

The Course and Communications of the Nerve Fibres in the Spinal 
Cord. Concerning the precise course of the nerve fibres proper to 






ANATOMY AND PHYSIOLOGY OF THE NEEVOUS SYSTEM. 5 

the spinal cord, and the manner of their communication with the 
nerve cells, very little is as yet positively determined. The discovery 
of branched ganglion nerve cells is, however, of the highest import- 
ance, as it suggests a medium of connection between the two nerve 
elements. Valuable information has also been derived from patho- 
logical (Tuerk), and embryological (Flechsig), investigations con- 
cerning the anatomical relations of certain white tracks of the cord 
to definite parts of the brain. The numerous longitudinal fibres of 
the cord evidently point to a connection between different parts of 
this organ, and to their destination in the brain ; but nothing definite 
is known respecting this anatomical arrangement. The same must 
be said of the multitude of horizontal and oblique fibres that traverse 
the spinal cord. Anatomical and physiological evidence establishes 
the fact that the motor fibres cross in the anterior pyramids, and con- 
tinue in their new course. In regard to the direction of the fibres 
which enter the posterior nerve roots, it is rendered highly probable 
that they ascend to the brain through the funiculi cuneatus and 
gracilis, which form the continuation of the posterior columns 
(Burdach's column). 

The Peripheral Expansion of Nerves. It is of great practical im- 
portance to become familiar with the peripheral distribution of the 
spinal nerves. Diseases of the cord frequently give rise to eccentric 
pains of a neuralgic or rheumatic character and other obscure affec- 
tions. 

The Functions of the Spinal Cord. The spinal cord is the only 
connecting link between the brain and the nerves of the trunk and 
extremities ; and must, therefore, contain all the nerve-paths of the 
latter. Modern neuro-physiology dates its beginning from the great 
discovery of Charles Bell, namely, that the anterior nerve-roots of 
the spinal cord consist of motor, and the posterior nerve-roots of sen- 
sory, fibres. This physiological law has no exceptions. 

In regard to the functions of the columns, it admits of no doubt 
that the anterior columns conduct motor impulses and the posterior 
sensory impressions. But the columns are not the direct prolonga- 
tions of the nerve-roots. Irritation of the anterior columns is not 
followed by muscular movements, if their nerve-roots are left undis- 
turbed ; and in a similar manner no sensation is evoked from irrita- 
tion of the posterior columns, if their nerve-roots are not involved. 
These observations led to the highly important distinction of sesthe- 



6 MANUAL OF NERVOUS DISEASES. 

sodic and kinsesodic substance. It appears that nerve tissue may be 
in a condition to transmit impulses, while it is itself incapable of 
being energetically acted upon by other modes of excitation — 
mechanical, chemical or electrical. Schiff has come to the following 
conclusions : The whole of the grey substance conducts sensibility. 
There is no exclusive relationship between certain parts of the grey 
substance and groups of sensitive nerves. Every portion of the grey 
substance transmits sensitive impressions. In section of the cord the 
less of the grey substance that remains, the less will be the trans- 
mission of sensibility. The grey substance itself is not sensitive, but 
easily transmits sensitive impressions (sesthesodie). An analogous 
explanation is applicable to transmission of motor impulses. A 
stimulus directed to the grey substance readily conducts an impulse 
to motor nerves (kinaesodic). Charles Bell was of the opinion that 
the lateral columns innervated the muscles of respiration, but physio- 
logical and pathological facts speak against it. That the lateral 
columns stand in intimate relation to the transmission of motor im- 
pulses there can be no doubt. 

The Spinal Cord a Center of Reflex Action. All sensitive nerves, 
the sympathetic as well as the spinal, are capable of exciting reflex 
action, and every muscle is subject to its influence. Keflex action 
consists essentially in the transmutation of one kind of nerve action 
into another kind. Its mechanism requires a centripetal nerve con- 
nected with a central nerve cell from which a centrifugal nerve goes 
to a muscle or irritable tissue. The anatomical construction and 
relations of the spinal cord completely answer such a purpose. Sup- 
pose a sensitive nerve in some part of the skin be irritated, the 
nervous stimulation thus induced travels to a ganglionic nerve cell 
in the spinal cord, and by an unknown process is there transmuted 
into an impulse which is propagated by a motor nerve connected 
with a muscle. The muscular movement which now ensues is the 
result of reflex action. Such a movement may be unilateral, sym- 
metrical, regular or disorderly, according to the direction and inten- 
sity of the initiatory irritation, and the number of implicated motor 
centers. If reflex action involves the general muscular system, as in 
tetanus and epilepsy, it must be assumed on physiological grounds that 
motor centers in the medulla oblongata are excited. Anaesthetics, but 
especially the application of powerful stimuli to the skin, diminish 
reflex excitability. It is increased in the inactive state of the brain 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 7 

during sleep, in strychnine poisoning, and in pathological conditions 
of the meninges. It is diminished or abolished in lesions of the 
lumbar region of the cord and by powerful cutaneous impressions. 

Inhibitory Function of the Spinal Cord. There are other influ- 
ences which are capable of retarding and even of checking reflex 
movements. We know that by an effort of the will we can sometimes 
control the reflex acts of coughing and sneezing, and by a volitional 
exertion are able to restrain, i. e. inhibit, the movements of our limbs 
when they are tickled. By inhibition, therefore, is meant the fact of 
impeded reflex action. Setschenow and others who have experi- 
mented on frogs for the purpose of determining the anatomical basis 
of these phenomena, came to the conclusion that "inhibitory centers" 
exist in certain parts of the brain and the spinal cord, which mod- 
erate reflex action. Whether such centers exist or not in the human 
subject, the fact remains that under certain circumstances an inhibi- 
tory influence is exerted on the functions of the spinal cord. 

The Spinal Cord a Center of Co-ordination. Voluntary muscular 
movements require a complex mechanism, by which groups of muscles 
that are sometimes widely apart from each other act together for the 
accomplishment of a definite purpose. Take for example the act of 
walking ; although the will gives the initiatory motor impulse, yet 
it has nothing to do with the selection and regulation involved in 
the play of muscles which must be brought into action. In fact the 
mind would be overwhelmed in making the attempt. Moreover, 
co-ordinate muscular movements also take place independently of 
volition. A brainless frog is still able to exhibit co-ordinate move- 
ments when parts of its body are irritated. Looking at the reflex 
apparatus in the spinal cord, it is not difficult to understand how 
such movements in the mutilated animal are brought about. It may 
be conceived that groups of nerve cells are arranged in such a way 
that in response to a sensory irritation, a motor impulse is excited, 
which acts upon muscles or groups of muscles that usually perform 
associate movements. Incoordination resulting from disease of the 
posterior columns of the cord, may be thus ascribed to the failure of 
peripheral stimulation to reach centers of co-ordination. There is, 
however, strong evidence to show that the spinal cord is not the 
primary organ of co-ordination. A frog whose brain is divided below 
the pons is still able to breathe, and to move his legs when they are 
irritated; but he cannot perform the complicated movements of 



8 MANUAL OF NERVOUS DISEASES. 

jumping and swimming; and when he is laid upon his back he 
cannot turn himself upon his feet. The centers of automatic action 
which, independent of the will, regulate a variety of complicated 
movements, are unmistakably located in the medulla oblongata ; and 
pathological investigations as well as physiological experiments have 
traced centers of co-ordination to the corpora quadrigemina, the 
cerebellum and the pons varolii. 

Trophic Influence of the Spinal Cord upon Peripheral Nerves. — 
Kecent investigations tend to sustain the opinion that the grey sub- 
stance of the spinal cord exercises an influence upon the nutrition of 
muscles. Degeneration and atrophy of muscles appear to be caused 
by destruction of ganglionic cells in the grey substance of the 
anterior horns. Such a lesion has been discovered in progressive 
muscular atrophy, in glosso-labio-pharyngeal paralysis, and in the 
spinal paralysis of children. 

The Influence of the Spinal Cord upon Involuntary 

Muscles. 

The Oculo- Spinal Center. Irritation of the anterior roots of the 
second and third cervical nerves, and of that portion of the spinal 
cord included between the sixth cervical and third dorsal nerves, 
produces dilatation of the pupils. On dividing the connection be- 
tween this pupillary center and the sympathetic, contraction of the 
pupils takes place. 

The Cenito- Urinary Center. Injury of the spinal cord is some- 
times followed by erection and ejaculations. In the squirrel there is 
a center in the lumbar region of the cord which, on being irritated, 
causes priapism. Irritation of the third and fourth sacral and fifth 
and sixth lumbar nerves produces contraction of the bladder in this 
animal. 

The Sphincters. The spinal cord exerts an important influence 
upon the functional integrity of the sphincters. The nerves of the 
bladder come from the lumbar region of the cord. The sensitive 
fibres are derived from the sympathetic, the motor fibres are dis- 
tributed to the detrusor muscle. Contraction of the bladder is a 
reflex act. Excitation of the sympathetic alone does not cause the 
expulsion of urine ; this requires the connection of the bladder with 
the spinal cord through the medium of an ex ci to-motor mechanism. 



THE HUMAN BRAIN, 




Fig. 1. — Side View of the Human Brain. 



F Frontal lobe. 
P Parietal lobe. 
Occipital lobe. 
T Temporal lobe. 
S Fissure of Sylvius. 
S / Horizontal. 
S // Ascending branch. 
C Central fissure (Fissure of Eo- 

lando. ) 
A Ascending frontal convolution. 
B Ascending parietal convolution. 
Fi, F$, F s , Superior, middle, inferior 

frontal convolution. 
fa /a> fa, Superior, inferior, vertical 

frontal fissure (precentral F). 
Pi Superior parietal lobule. 



P 2 Inferior parietal lobule (Gyrus su- 
pramarginalis). 

P 2 / Gyrus angularis. 
ip Interparietal sulcus. 

cm Extremity of the Sulcus calloso 
marginalis. 

O x , 02, 3 , First, second, third occipi- 
tal convolution. 

Po Fissura parieto-occipitalis. 
o Transverse occipital fissure. 
2 Sulcus occipitalis longitudinales 
inferior. 

Ti,T3 t Ta, First, second, third temporal 
convolution. 

ti, t 2 , First, second temporal fissure 
(Ecker). 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. \) 

The regulation of the sphincter does not entirely depend upon 
its direct connection with the lumbar nerves, as disturbances of the 
function of the bladder are also caused by lesions of the cervical and 
dorsal regions of the spinal cord. 

The Brain. 

The lobes of the cerebral hemispheres are named in accordance 
with the respective cranial bones that cover them. They comprise 
the frontal, parietal, temporal, and occipital lobes. 

The Fissures or Sulci. The surface of each hemisphere is marked 
by furrows that run in different directions, seemingly without any 
fixed order. But on comparing the brains of different species of 
mammals, fissures of an analogous description can be recognized 
which are constant. These fissures mark the boundaries of the con- 
volutions. 

The Fissure of Sylvius. This is the most constant of all the 
fissures, and is already developed in the third month of embryonic 
life. It commences on the under surface of the brain, and is formed 
by the folding of the whole hemisphere downwards, like an arch 
around the crura cerebri. This fissure divides into two branches — a 
short anterior branch which ascends towards the frontal lobe, and a 
long posterior branch which takes a horizontal course in the direc- 
tion of the parietal lobe. At its bifurcation it forms a fossa, in which 
the insula of Eeil is situated, covered by the operculum. 

The Central Fissure, or the Fissure of Rolando, runs in a nearly 
vertical direction from the upper margin of the hemisphere towards 
the posterior division of the Sylvian fissure. 

The Intro-parietal Fissure begins at the angle formed by the central 
fissure and the posterior branch of the Sylvian, and passes backward 
in the direction of the parieto-occipital fissure. 

The Parieto- Occipital Fissure is composed of a median and a 
lateral part. Its median portion is constant and deep, and divides 
the parietal from the occipital lobe. The lateral portion is short, 
but sometimes it extends in an oblique direction over a considerable 
part of the hemisphere. 

The Fissures of the Median Side of the Hemispheres. The prin- 
cipal fissures in this region comprise the sulcus calloso-marginalis, 



10 MANUAL OF NERVOUS DISEASES. 

which runs for a short distance from the upper margin of the hemi- 
sphere in a vertical direction, then making a turn, runs parallel with 
the corpus callosum. The calcarian fissure is formed by the junction 
of two small furrows and takes a horizontal direction. The superior 
extremity of the central fissure extends a little way to the median side. 

The Fissures of the Inferior Surface of the brain are mostly the 
continuations of the sulci that have already been described, and will 
be again mentioned in connection with the convolutions of which 
they form the boundaries. 



The Convolutions. 

Convolutions of the Frontal Lobe. The frontal lobe is bounded on 
its superior and lateral sides by the fissure of Rolando, which divides 
it from the parietal lobe; on the inferior side by the vertical branch 
of the Sylvian fissure and the substantia perforata, that divides it 
from the temporal lobe. There is no marked line of division on the 
median side between the frontal and temporal lobes. 

The Ascending Frontal Convolution. This convolution runs 
upward in front of the central fissure and unites at both ends with 
the convolution on the opposite side of this fissure. These two con- 
volutions are usually spoken of as the " central convolutions." 

The Superior or First Frontal Convolution. This convolution 
starts from the upper portion of the ascending frontal, and runs 
forward where a number of irregular furrows subdivide it into minor 
elevations. Its median portion is bounded by the calcarian fissure. 
Its narrow extremity on the inferior surface of the frontal lobe is- 
called the gyrus rectus. 

The Middle or Second Frontal Convolution. This convolution is a. 
continuation of the upper end of the first convolution, and runs 
forward where it subdivides into a number of complicated elevations. 
Inferiorily it fills the orbital fossa. 

The Inferior or Third Frontal Convolution. This convolution is a 
prolongation of the lower portion of the central, and forms a part of 
the operculum. From there it winds around the vertical branch of 
the Sylvian fissure, and going forward and then downward, forms the 
lateral aspect of the frontal lobe (Broca's convolution). 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 11 

« 

Convolutions of the Parietal Lobe. The parietal lobe is separated 
in its superior aspect from the frontal lobe by the central fissure ; 
from the temporal lobe by the Sylvian fissure, and imperfectly from 
the occipital lobe by the parieto-occipital fissure. The calloso- 
marginalis fissure forms a complete boundary on the median side 
between the parietal and the occipital lobes. 

The Ascending Parietal Convolution. This convolution runs par- 
allel with the ascending frontal on the posterior side of the central 
fissure. The first and second parietal convolutions (posterior and 
inferior parietal lobules) run backward from the ascending convolu- 
tion and are separated by the introparietal fissure. They are marked 
by numerous narrow furrows which divide and subdivide them into 
small elevations. 

The Praecunial Convolution (Quadrate Lobule). This convolu- 
tion is a prolongation of the superior portion of the ascending 
parietal convolution. After curving backward it enlarges and forms 
a square-shaped lobule, which is composed of a number of minor 
convolutions. It extends to the parieto-occipital fissure, which com- 
pletely separates it from the first occipital convolution (cuneus). On 
the median side it is sharply defined by the calloso-marginal fissure. 

The Third Parietal Convolution. This is an exceedingly compli- 
cated and ill-defined convolution. It is usually divided into an 
anterior and posterior portion. The former is also called the lobulus 
supra-marginalis, and is situated between the lower end of the 
ascending parietal convolution and the upper extremity of the 
Sylvian fissure. It forms there a part of the operculum, and presents 
several lobules that curve around the end of the fissure, and termin- 
ates in the first temporal convolution. The posterior portion, or the 
gyrus angularis, is bounded above by the introparietal fissure, unites 
with the occipital lobe, and then, in the form of an arch, folds around 
the first temporal fissure, where it unites with the second temporal 
convolution. 

The Convolutions of the Temporal Lobe. The temporal lobe fills 
the sphenoidal fossa and forms the smallest portion of the hemi- 
sphere. It presents only two sides, a lateral and an inferior. The 
Sylvian fissure divides this lobe from the whole of the frontal and 
partly from the parietal lobe; but on its inferior surface it can 
hardly be distinguished from the posterior portion of the parietal 



12 MANUAL OF NERVOUS DISEASES. 

and from the occipital lobes. Hence it is convenient to consider the 
under surface of both lobes as the occipito-temporal lobe. The con- 
volutions of the temporal lobe are also very complicated on account 
of the extreme variableness of its fissures. A rather constant fissure, 
running parallel with the Sylvian, encloses the gyrus infra-margin- 
alis (first temporal convolution), which, folding around the upper 
end of the latter fissure, is lost in the supra-marginal convolution. 
The middle or second temporal convolution has for its upper bound- 
ary the first temporal convolution, and posteriorly the angular gyrus ; 
but on its inferior side it unites, to a great extent, with the third 
temporal convolution. 

Convolutions of the Occipital Lobe. As the calcarian and the 
parieto-occipital fissures form an acute angle on the median surface 
of the hemisphere, a triangular, or rather a wedge-shaped portion of 
the brain is thus cut off, with its base directed upward and backward, 
and its apex downward and forward. This is the cuneiform convo- 
lution, or the internal occipital lobule. The portion of the occipital 
lobe below this convolution cannot be distinguished from the con- 
tiguous convolution of the temporal lobe. The inconstant and 
* c bridging " convolutions on the superior and lateral aspects of the 
occipital lobe, render their description an extremely difficult task. 
Authors distinguish, however, a superior, middle, and an inferior 
occipital convolution. 

The Convolutions of the Base of the Brain. These convolutions 
posterior to the fissure of Sylvius, belong partly to the temporal and 
partly to the occipital lobe. The former is marked by a deep and 
constant fissure which divides it into two convolutions, — the lingualis 
and the fusiform lobules. The occipito-temporal convolution, as its 
name indicates, is formed by the union of outer portions of the 
temporal and occipital lobes. All the convolutions in this region of 
the base of the brain run in a horizontal direction. 

The Convolutions of the Median Surface of the Brain. Most of 
these convolutions have already been described. The gyrus forni- 
catus is the most conspicuous convolution on the median side of the 
hemispheres. It is bounded above by the calloso-marginalis fissure 
and winds around the corpus callosum. Toward its posterior, ex- 
tremity it becomes narrow, turns downward and forms the gyrus 
hippocampi. 

The foregoing is but a meagre account of the labyrinth of 



THE MONKEY BRAIN. 
( Cerocebus cinomolgus. ) 
c 




Fig. 2. 



1 Inferior extremity of the forehead. 

2 Inferior extremity of the occiput. 

3 Inferior extremity of the temple. 

4 Cerebellum. 

5 Medulla oblongata. 
FS Fissure of Sylvius. 

AB Posterior or ascending branch. 
G Central fissure (Fissure of Rolando). 



F x Inferior frontal fissure. 

F<x Superior frontal fissure. 
PC Paracentral fissure. 

IP Interparietal fissure. 
PF Parallel fissure. 
EF External occipital fissure (mon- 
key fissure). 

OL Occipital lobe (Meynert). 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 13 

convolutions presented by the human brain. To overcome some 
of the difficulties in studying this complex anatomical arrangement, 
it is advisable to compare the simple conformation of the cerebral 
surface in the monkey, with that of the human brain. 

The Cortex. Histologists distinguish five layers of nerve cells in 
the cortex. The cells are of various shapes and sizes. Some are 
branched, others are pyramidal, oval or irregular. Many of them 
occur in groups separated by bundles of radiating nerve fibres. 

Physiology reaches its limits when it assigns to the cortical sub- 
stance of the hemispheres the highest position in the order of reflex 
apparatus whose operations are associated with consciousness. The 
following considerations point to the intimate relation existing be- 
tween the cortex and the manifestations of intelligence, emotion, 
will, etc. 

1. The development of the brain in animals increases in proportion 
to their intellectual capacities. This is especially noticeable in the 
number and complexity of the convolutions which enlarge the area 
of the cortical substance. 2. Congenital smallne'ss or degeneration 
of the superior hemispheres, as observed in hydrocephalus and in 
cretinism, is invariably accompanied by a corresponding diminution 
of the mental powers. 3. Injury and disease of the hemispheres 
give rise to states of mental excitement, confusion of ideas, stupor or 
coma, etc. 

The Localization of the Functions of the Brain. Eminent neu- 
rologists of a past period acknowledged no difference in the functions 
of limited areas of the cortex. The so-called system of phrenology 
of Gall is an untenable superstructure founded on unreliable data. 
It was only when Broca began to offer anatomical evidences of the 
existence of a " speech center " that a new impetus was given to the 
inquiry concerning the localization of brain functions, and which led 
to the remarkable experiments of Fritsch, Hitzig and Ferrier. The 
methods employed by these observers and the results they obtained 
were as follows : When limited areas of the brain surface were stim- 
ulated by the galvanic current, the animal made certain uniform 
movements ; and conversely, when the same areas were extirpated, 
such movements could not be evoked for at least a considerable time. 
Thus the animal would move a foreleg, a hindleg, or the eye when- 
ever the electric stimulus was applied to a particular spot of the 
cortex. On this principle the cortical surface is mapped out in so- 



14 MANUAL OF NERVOUS DISEASES. 

called psycho-motor centers. Ferrier's figures are constructed on 
such a plan. In those areas of the human brain which correspond 
to analogous areas of the monkey brain, he localizes the centers 
for the special movements which the experiments had elicited and 
marked them accordingly. From these figures it appears that the 
principal " motor zone " is located about the superior portions of the 
ascending frontal and ascending parietal convolutions, i. e. those 
convolutions which are in the immediate neighborhood, or on each 
side of the upper portion of the fissure of Kolando. It is a significant 
fact that large pyramidal cells abound in this region of the cortical 
layer. 

The Function of Speech. Circumscribed lesions of the left hemi- 
sphere affecting the island of Eeil or its adjacent parts, — the third 
frontal and superior parietal convolutions, — are now so frequently 
found in connection with defects or loss of speech, that the existence 
of a " speech center " may be accepted as an established fact in cere- 
bral physiology. Disturbances of speech due to pathological changes 
of said regions of the brain are classed under the common name 
aphasia. An aphasic patient may have completely lost the memory 
of words, or he may be able to repeat them on dictation, or copy 
them in writing though he does not understand their meaning. He 
is therefore unable to convey his thoughts in language ; the fault 
being here on the intellectual side, — this is "amnesic aphasia." 
Another aphasic patient remembers words and their meanings very 
well, and can make himself understood in writing, but is incapable 
of giving utterance to his thoughts in articulate language; he cannot 
co-ordinate the movements involved in speech ; the fault being here 
on the motor side, — this is "ataxic aphasia." A number of other 
disturbances of speech having the dysphasic character are met with, 
resulting from disease of the mentioned portions of the brain. 

The Functions of the Central Ganglia. The central, or, as they 
are frequently called, the "basal ganglia," consist of the corpora 
quadrigemina, the thalami optici, and the corpora striata. These 
grey masses, in view of their central location and their extensive con- 
nections, evidently subserve highly important functions, which are 
but imperfectly known. It is certain that they constitute nervous 
mechanisms which, under normal conditions, induce reflex and co- 
ordinate movements, independent of volitional impulses. Very sin- 
gular movements of a compulsory nature are witnessed in animals 
when these nervous masses are injured or destroyed. The animals 



PSYCHO-MOTOR CENTERS. 




Fig. 3. — Side and Upper View of the Brain ov Man. 
(According to Ferrier.) 

I On the posterior parietal (posterior parietal lobe). Advance of the opposite 

hind limb, as in walking. 

2, 3, 4 Around the upper extremity of the Fissure of Rolando. Complex move- 
ments of the opposite leg and arm and of the trunk, as in swimming. 

a, b, c, d On the posterior parietal (posterior central convolution). Individual 
and combined movements of the fingers and wrist of the opposite hand. 
Prehensile movements. 

5 At the posterior extremity of the superior frontal convolution. Extension 
forward of the opposite arm and hand. 

o On the upper part of the antero-parietal or ascending frontal convolution 
(anterior central). Supination and flexion of the opposite forearm. 

7 On the median portion of the same convolution. Retraction and elevation of 

the opposite angle of the mouth by means of the zygomatic muscles. 

8 Lower down on the same convolution. Elevation of the ala nasi and upper lip. 
9, 10 At the inferior extremity of the same convolution (Broca's). Opening of 

the mouth with protrusion (9) and (10) retraction of the tongue. Region 
of Aphasia. Bilateral action. 

II Between (10) and (11) and the inferior extremity of the posterio-parietal 

convolution. Retraction of the opposite angle of the mouth ; the head 
turned slightly to one side. 

12 On the posterior portion of the superior and middle frontal convolution. 
The eyes open widely, the pupils dilate, and the head and eyes are turned 
toward the opposite side. 

13, 13' On the supra-marginal lobule and angular gyrus. The eyes move 
towards the opposite side with an upward (13) or downward (13') devia- 
tion. The pupils generally contracted. Center of vision. 

14 On the infra-marginal or superior (first) tempero-sphenoidal convolution. 
Pricking of the opposite ear ; the head and eyes turn to the opposite side 
and the pupils dilate largely. Center of hearing. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 15 

show an irresistible tendency to roll around the longitudinal axis of 
the body, or move continually in a circle either toward or away from 
the side (circus movements, manege). Certain forms of vertigo 
appear to be due to a similar defect in the working of the co-ordinat- 
ing machinery located somewhere in these basal ganglia. In an affec- 
tion of the semicircular canals of the internal ear (Menier's disease), 
there exists a tendency in the individual to fall over on one side. 

The Corpora Quadrigemina. Destruction of the corpora quadri- 
gemina in animals prevents contraction of the pupils. Irritation of 
the anterior nates causes dilatation of the pupil on the affected side, 
and also movement of the eyeballs toward the opposite side. From 
these movements, and from the fact that the corpora quadrigemina 
are directly connected with the optic nerve and the nucleus of the 
motor oculi, it may be concluded that this organ is the center for the 
movements of the pupils and of the eyeballs. 

The Thalami Optici. The inference that this organ is a sensory 
center rests upon its connection with certain tracts of nerve fibres of 
the spinal cord that pass upward to the hemispheres. This opinion 
receives additional support from pathological and clinical observa- 
tions ; but direct evidence from experimental investigations is want- 
ing. Experiments on pigeons appear to indicate that the thalamus 
is concerned in the function of vision. When injured, it gives rise to 
forced movements. 

The Corpus Striatum. This central mass includes the caudate 
body and the lenticular nucleus. From its close connection with the 
peduncles of the brain, and from the fact of its great development in 
the higher order of animals, it is inferred that the functions of this 
organ are of an important character. The striated body is probably 
concerned in the operation of conscious sensations and movements. 
Injury to the lenticular nucleus is invariably followed by hemiplegia 
of the opposite side. 

The Crus-Oerebri and Pons- Varolii. The functional importance 
of these parts of the brain is evident from their intermediate position 
between the higher centers and the spinal cord. Pathological 
changes in these organs must, therefore, necessarily give rise to very 
serious symptoms. 

The Cerebellum. This organ is a center of co-ordination. Injury 
to the cerebellum in birds prevents the act of flying. A tottering 



16 MANUAL OF NERVOUS DISEASES. 

gait is one of the most common symptoms in cerebellar disease. The 
belief that the sexual instinct has its seat in this organ is not sup- 
ported by sufficient evidence. 

The Functions of the Medulla Oblongata. In the disposition of the 
grey and white substances there is considerable difference between 
the medulla oblongata and the spinal cord, but less in regard to 
function. The physiological importance of the medulla exceeds that 
of any other portion of the cerebro-spinal axis. It contains not only 
the roots of all the cranial nerves from the sixth downward, but also 
those automatic and reflex centers which are indispensable to the 
maintenance of the general system. They may be briefly enumerated 
as follows : 

1. The Respiratory Center. Injury to a spot near the calamus 
scriptorius suddenly stops the act of respiration, causing death in 
warm-blooded animals. 

2. The Cardio- Inhibitory Center. This center regulates the action 
of the heart ; certain nerve fibres from the pneumogastric are con- 
nected with this organ. Their irritation retards or inhibits cardiac 
action. 

3. The Vaso- Motor Center. This consists of a group of large mul- 
tipolar cells in the upper part of the fourth ventricle, from which a 
system of nerves arises that enters the spinal cord, and are distributed 
to the muscular coats of the arteries and capillaries. 

4. The Center for Deglutition. Spasmodic efforts of deglutition 
are observed when the medulla is morbidly excited. The precise 
location of this center has not been determined. Deglutition being 
a reflex act, it resembles, in this respect, the orderly reflexes of the 
spinal cord. On similar grounds it is inferred that the innervation 
of masticatory movements comes from a center in the medulla. 
Irritation of this center induces the phenomenon of trismus. It 
must be understood that the central apparatus of these reflex move- 
ments is also controlled by voluntary impulses. 

5. Diabetic Center. Injury of the floor of the fourth ventricle 
causes a temporary increase of the urinary excretion (diabetes 
insipidus). Recent investigations render the existence of a gluco- 
genetic center doubtful. It is more probable that diabetes mellitus 
depends upon lesion of the vaso-motor center which causes paralysis 
of renal and hepatic vessels. 

The fact that vomiting without a palpable cause is frequently wit- 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 17 

nessed in brain affections has suggested the existence of a center in 
the medulla controlling the movements of the stomach; but the 
gastric disturbance can be better explained on the supposition that 
it is of a reflex character, depending upon excitation of the pneumo- 
gastric. 

The Arterial Circulation of the Brain. The peculiarities of the 
arterial circulation in the brain exercise an important influence on 
the pathology of this organ. Unlike the spinal cord, with its well- 
defined systems of nerve tracts, the encephalon presents no such clear 
anatomical divisions'; but, owing to the arrangement of its arterial 
distribution, cerebral lesions are apt to occur in certain vascular 
districts. This is particularly true of cerebral hemorrhage and 
softening. 

The brain derives its red blood from two sources — the vertebral 
arteries and the internal carotids. The former unite and form the 
basilar artery, which gives off the two posterior cerebral arteries. The 
carotids divide at the base of the brain into two large branches — the 
anterior cerebral and the middle cerebral arteries. These two sets of 
arteries unite by anastomosing vessels, and form the circle of Willis. 
A large number of nutrient vessels, coming from each of their 
principal branches, penetrate the brain and furnish it with arterial 
blood. The vascular system belonging to the middle cerebral artery 
will be considered first. This artery enters the fissure of Sylvius and 
there divides into several branches. Its cortical branch is distributed 
to the third frontal convolution, to the two central convolutions and 
to the parieto-temporal convolution. Its internal branch goes to the 
greater part of the caudate body of the corpus striatum, to the whole 
of the lenticular nucleus, to a portion of the thalamus opticus, and to 
the internal capsule. Branches of the anterior cerebral artery go to 
the convex and basal side of the first and second frontal convolutions 
and to the inferior portion of the ascending frontal convolution. The 
posterior cerebral artery sends branches to portions of the temporal 
convolutions, to the whole occipital lobe, to a portion of the thalamus 
opticus, to the peduncles of the brain, and to the corpora quadri- 
gemina. It is important to remember that, although the cortical 
central systems of the arterial ramification in the brain have a common 
origin, yet they do not anastomose at any point. 

The Sympathetic System of Nerves. Much obscurity prevails con- 
cerning the functions of this portion of the nervous system. The 



18 MANUAL OF NERVOUS DISEASES. 

old opinion that the ganglionic system of nerves is exclusively engaged 
in the innervation of the vegetative organs is now abandoned. It is 
certain that they transmit impulses to the nerve centers precisely in 
the manner of the cerebro-spinal nerves. Many physiological and 
pathological theories take it for granted that the ganglions constitute 
independent centers of nerve action. 

The Vaso- Motor System of Nerves. Claude Bernard's brilliant 
experiment demonstrated the existence of a class of nerves (probably 
a part of the great sympathetic) which are distributed to the con- 
tractile tissue of arteries, veins and capillaries. They subserve the 
following important functions : 1. The " tone " of the arterial circula- 
tion depends upon the constant action of these nerves. 2. They 
regulate the blood pressure in accordance with the wants of the 
general system. 3. By means of a reflex mechanism, they act in- 
directly on circumscribed vascular districts. 4. Direct excitation of 
the vaso- motor center, as in blushing, causes localized vascular dila- 
tation. 5. Vaso-motor disturbances produce local changes of tempera- 
ture, resulting either from an increased or diminished amount of 
blood in the vessels in proportion to the dilatation or constriction of 
their calibre. 

Strong evidence has been brought forward to prove the existence 
of distinct vaso-constrictor, vaso-dilator, and secretory nerves. 

Trophic Nerves. A great number of clinical observations suggest 
the existence of a particular set of nerves that influence the nutrition 
of tissues. Magendie divided the trunk of the trifacial nerve and 
witnessed, in consequence, the destruction of the eyeball. Section of 
motor nerves causes degeneration and wasting of the muscular fibre. 
The observations of Weir Mitchell are exceedingly interesting. This 
author describes a variety of "trophic" changes resulting from 
injuries to peripheral nerves. Among them he mentions a peculiar 
condition of the skin, especially marked in the fingers and toes, 
which presents a glossy appearance. The cutaneous eruption in 
herpes zoster is probably due to "trophic" disturbances. Austie 
observed a white patch of hair over the course of the affected nerve 
in neuralgia of the scalp. Still the existence of a distinct class of 
" trophic " nerves is problematical, for the role assigned to them may 
be properly ascribed to the action of vaso-motor nerves. 



Third Ventricle 



External 
Capsule 



Claustrum 



Lenticular Nucleus 

Horn of Amnion 




Claustrum 



Sphenoidal Horn 
of Lat. Ventricle 



Post-cerebral Arteries 



Fig. 4. — Vertico-trans verse Section of the Brain, posterior to the 
tubercula mammillaria, anterior to the peduncle. — (gjiatcot.) 



anatomy and physiology of the nervous system. 19 

The System of Communicating Nerve Fibres in the Brain. 

The white or medullary substance of the brain consists almost 
exclusively of nerve fibres. They may be thus divided : 

1. Associating fibres, which connect different portions^of the cortical 
substance. 2. Commissural fibres, which unite symmetrical parts of 
the brain (corpus callosum, anterior commissure). 3. Eadiating 
fibres, which keep up communication between the cortex, the basal 
ganglia and the spinal cord. Meynert classifies all the sensitive and 
motor fibres on the principle of their projection in the brain. He 
adopts three " orders " of such a projection system. The first order 
connects the cortex with the large central ganglia (corona radiata) ; 
the second connects these ganglia with the grey substance of the 
medulla oblongata and of the spinal cord (peduncles), and the third 
composes the peripheral expansion of fibres. 

For the purpose of gaining a clearer conception of the reciprocal 
relations of the grey masses of the brain and the communicating 
nerve fibres, it is best to make a number of vertico-transverse sections 
of the brain at different levels. The annexed diagram, from Charcot, 
presents such a section at the level of the corpora quadrigemina. 

At the inferior and median part of the section two large white 
tracts of nerve fibres, called the internal capsules, are observed, 
which diverge toward the cortical substance of the hemispheres. 
These tracts are the prolongations of the cerebral peduncles. Their 
fan-shaped expansion to all the lobes of the brain is named the 
corona radiata. The internal capsule separates two central masses 
of grey matter; the one superior and internal, the other inferior 
and external. The grey mass which is above and inside of the 
capsule, is the thalamus opticus. The smaller mass is the head 
of the caudate body of the corpus striatum ; the one on the outside 
and below the internal capsule is the lenticular nucleus with its 
three segments. The external capsule, which is also composed of 
a bundle of nerve fibres, is on the outside of the latter ; and next to 
this, a grey lamina, the claustrum, which faces the island of Keil. 

Nature of Nerve Action. The intrinsic change that takes place in 
a nerve when in a state of excitation is only a matter of speculation. 
Two hypotheses may be conceived in explanation of nerve action. 
The one refers the phenomenon of the transmission of sensory and 
motor impulses to molecular action. It assumes that the nerve 



20 



MANUAL OF NERVOUS DISEASES. 



molecule to which the stimulus is applied, imparts its movement to 
its next neighbor, and so on throughout the whole series of molecules, 
resembling the communication of movement in a row of balls. The 
other hypothesis ascribes the nervous impulse to a chemical change, 
which liberates force stored up in the nervous tissue, like the dis- 
charge from the firing of a train of gunpowder by a spark. 



OHAPTEK II. 

GENEKAL SYMPTOMATOLOGY OF NERVOUS 
DISEASES. 

Sensory Disturbances. 

Hyperesthesia signifies augmented sensibility. In this abnormal 
condition of the nervous apparatus, ordinary stimuli produce painful 
sensations and evoke a heightened reflex excitability. Some source 
of irritation must therefore be assumed to dispose a sensory nerve, a 
nerve-root, or more especially the spinal cord, to react with exagge- 
rated intensity. Hypergesthesia is a prominent symptom in spinal 
meningitis, hydrophobia, tetanus, strychnia-poisoning, and hysteria. 

New terms have lately been introduced to distinguish with greater 
precision the different varieties of disturbed sensation. Hyperalgia 
denotes exaltation of common sensations; Analgia, the opposite con- 
dition; Hyperalgesia refers to pain and the important class of 
neuralgic affections; Analgesia designates that abnormal state of 
sensibility in which no pain can be elicited in certain regions of the 
skin. 

Pain. Although pain is emphatically a subjective symptom, and 
therefore, as a general rule, unreliable for diagnostic purposes, yet it 
not unfrequently constitutes the only evidence of disease. In illus- 
tration of this fact, it is only necessary to allude to the knee pain 
of hip-joint disease; the double sciatica of loco-motor ataxy; the 
violent paroxysmal pains of internal aneurisms, etc. An accurate 
knowledge of nerve- intercommunications often clears up an obscure 
affection which gives no other intimation of its existence than pain 
in distant parts of the body. This subject will again come under 
consideration in connection with neuralgia. 

Anesthesia. Diminution and complete loss of cutaneous sensi- 
bility constitute the principal, but not the only forms of anaesthesia. 
Anaesthesia is also recognizable by retarded transmission of sensory 



2S2S MANUAL OF NERVOUS DISEASES. 

impressions. The different qualities of sensibility may be collectively 
or only partly abolished. Tactile sensation is conveniently tested by 
touching the skin with a blunt instrument ; pain, by the pricking 
of a needle ; thermic sensibility, by the application of a warm or 
cold substance ; the capability of localizing sensations, by touching 
certain regions of the skin whilst the patient has his eyes closed ; and 
spatial differences between points of contact, by varying the distance 
between the points of a compass. The muscular sense is judged by 
the appreciation of weights. When greater accuracy- is desirable, 
it is best to make use of the instruments devised for such experiments, 
as the aesthesiometer, dynamometer, etc. 

Incomplete Ancesthesia is commonly recognized by the feelings of 
numbness and furriness. Patients sometimes experience a sensation 
at the finger ends as though they were covered with silk ; or they 
have a sensation at the soles of the feet as if standing or walking on 
an elastic substance. 

Paresthesia. Certain undefinable sensations of a distressing char- 
acter are designated by this term. What is called " precordial 
anxiety" resembles a feeling of compression or constriction in the 
region of the heart. It occurs in nervousness and hysteria, but with 
greatest severity in angina pectoris. Various other subjective symp- 
toms are usually grouped among these morbid sensations, such as 
formication, tingling, pricking, a feeling as if the part were asleep, 
flushes of heat or chilliness in different parts of the body, due, prob- 
ably, to local vaso-motor disturbances. 

Local Ancesthesia. Anaesthesia of peripheral origin is witnessed 
in traumatic lesions of nerve-trunks, in neuritis and pressure of 
tumors. The circumscribed anaesthesia from the application of cold, 
or rather the abstraction of heat, is utilized by the surgeon by means 
of the ether spray. Numbness of the finger ends is a common com- 
plaint among washerwomen. Persons who follow occupations that 
require the constant handling of fine metallic substances, or who 
expose their fingers to the action of acid fluids, often suffer from a 
similar form of local anaesthesia. 

Spinal Ancesthesia. Lesions of the grey Substance and of the pos- 
terior columns of the spinal cord interrupt the transmission of 
sensory impressions from the periphery to the perceptive centers, 
and must necessarily give rise to cutaneous anaesthesia. Traurnatic 



GENERAL SYMPTOMATOLOGY OF NERVOUS DISEASES. 23 

injuries to the cord are nearly always followed by loss of sensibility, 
for usually the whole thickness of this organ becomes involved, and 
hence sensory and motor paralysis in the form of paraplegia is the 
rule in this class of cases. Bilateral or symmetrical anaesthesia, mostly 
of the lower extremities, is, with rare exceptions, characteristic of 
spinal disease. The extent and completeness of spinal anaesthesia 
vary with the spread and intensity of the lesion. Progressive 
anaesthesia in spinal affections is due to ascending secondary 
degeneration. 

Oerebral A ncesthesia. As the localization of sensory centers in the 
brain is far from being satisfactorily determined, we must look for 
information to the morbid anatomy in those diseases of the encephalon 
which are accompanied by loss of cutaneous sensibility. Anaesthesia 
has been observed in lesions of the medulla oblongata, the pons 
varolii, the crura cerebri, the basal ganglia and the cortical substance. 
But in the vast majority of cases the anatomical changes will be 
found in one of the following parts of the brain : the superior portion 
of the thalamus opticus, the third segment of the lenticular nucleus 
and the inferior third of the internal capsule. Incomplete and 
circumscribed loss of cutaneous sensibility is, in general, character- 
istic of anaesthesia from brain lesion. In abscess and tumors of the 
brain, the symptoms of irritation and excitement predominate. Anaes- 
thesia can be frequently discovered in chorea, epilepsy, and the 
cataleptic state. Hemianaesthesia is common in hysteria. 

Motor Disturbances. 

The subjects for consideration under this head include the 
important groups of paralytic and convulsive affections. 

Paralysis (Akinesia). Paralysis means a state of more or less 
immobility of muscular organs dependent on a want of motor inner- 
vation. Loss of muscular power from any other cause is not, strictly 
speaking, paralysis. In every case of paralysis some pathological 
change must have taken place in the nervous system which either 
interferes with the volition or the conduction of motor impulses. If 
this morbid alteration involves the center of volition, although the 
rest of the nervo-muscular apparatus be intact, no voluntary move- 
ment can occur ; and, similarly, if the volitional center be free, but 
the paths which connect it with muscular organs are interrupted. 



24 MANUAL OF NERVOUS DISEASES. 

paralysis must necessarily ensue. The general muscular relaxation 
in states of unconsciousness, and the immobility observed in hysterical 
patients due to abeyance of the will, are examples of true central 
paralysis. Practically, however, it is the paralysis resulting from 
anatomical alterations of the brain and of the spinal cord that is 
mainly to be considered. 

Cerebral Paralysis. Hemiplegia is the typical form of paralysis 
in brain disease. It is a cross paralysis, for the loss of voluntary 
motion is on the side of the body.opposite to that of the lesion. The 
loss of muscular power may be complete or incomplete (paresis), or 
the several parts may be affected in different grades of intensity. 
Hemiplegia usually affects one side of the face and the upper and 
lower extremities of the same side. Alternate paralysis occurs in 
lesions of the pons and peduncles — monoplegia in diseases of the 
cortex. General paralysis, in which both sides of the body are simul- 
taneously affected, is but rarely witnessed, as it rapidly leads to a 
fatal termination. Cases of cerebral paralysis may present all the 
clinical features of the peripheral variety. This will happen if, for 
example, the motor oculi be caught by a lesion at the base of the 
brain, which is not an uncommon occurrence in intracranial syphilis. 

Head Symptoms. The general symptoms common to many diseases 
of the brain and the meninges are usually spoken of as "head 
symptoms." Their diagnostic importance mainly depends upon the 
presence of more significant signs of cerebral trouble. Functional 
disturbances of the brain, it must be remembered, are exceedingly 
common in all acute febrile conditions, and in many affections of 
remote organs. They come and go with the primary disorder and 
usually attract but little attention. The chief cephalic symptoms 
comprise headache, vertigo, delirium, insomnia, somnolence, stupor, 
coma, and general convulsions. 

Among the adventitious symptoms may be enumerated nausea, 
vomiting, constipation of the bowels, and disturbances of sight and 
hearing. 

Headache. Violent and persistent pain in the head is a constant 
symptom in acute meningitis, cerebral abscess and intracranial tumors. 
The pain may be limited to a certain spot or shift from one place to 
another, or be diffused over the whole head. Sometimes patients 
complain only of fullness, weight, or constriction of the head. Ursemic 
convulsions are often ushered in by intense headache. Children 



GENERAL SYMPTOMATOLOGY OF NERVOUS DISEASES. 25 

manifest severe pain in the head by a peculiar abrupt, piercing 
cry, and by boring the head into the pillow. The pathology of head- 
ache is very obscure. Physiology teaches that the brain substance is 
insensible to pain. The dura-mater, however, becomes highly sensi- 
tive when morbidly affected. This membrane receives filaments from 
the trigeminus. 

Vertigo. This symptom frequently accompanies headache. In 
most cases it merely amounts to a slight feeling of dizziness. Well 
marked vertigo is common in cerebral anaemia. It is occasionally 
due to an affection of the ocular muscles, and is a prominent symptom 
in Menier's disease. 

Delirium. The mental disturbance designated by this term 
embraces aberration of the senses and delusions. Delirium may 
assume all conceivable grades of intensity, from mere confusion of 
mind or wandering, to a state of maniacal excitement. It is recog- 
nized by incoherence of language, false and fanciful ideas, and 
disorderly or violent conduct. Although delirium presents all the 
clinical features of insanity, it is distinguished from the latter by the 
fact that it is only a symptom and not a substantive mental disease. 
Like headache, it makes its appearance under the influence of various 
and opposite pathological conditions, and for this reason it is ordi- 
narily a symptom of little diagnostic value. In certain nervous 
affections, however, the peculiarity of the hallucinations or delusions 
is of some significance. Thus the hallucinations of delirium tremens 
are usually repulsive to the patient and inspire his fear. The delu- 
sions of the demented paralytic partake of exaltation and grandeur. 

Insomnia. Somnolence. Coma. The function of sleep is variously 
disturbed during the course of many cerebral affections. An excited 
condition of the brain is incompatible with quiet and rest. Patients 
complain of wakefulness, and the short snatches of sleep are dis- 
turbed by unpleasant dreams. Prolonged insomnia is a very grave 
symptom. Drowsiness is frequently a premonitory sign of brain 
trouble in children. Grinding of the teeth, champing of the lips, and 
sudden starts during sleep, often announce an attack of infantile con- 
vulsions. Somnolence is not unfrequently the precursor of the more 
serious symptoms of uraemic poisoning. The usual mode of death in 
fatal brain diseases is by coma. It indicates paralysis of the nerve 
centers, mostly from compression, and may alternate with or imme- 
diately follow general convulsions. 



26 MANUAL OF NERVOUS DISEASES. 

Nausea; Vomiting. These gastric disturbances are sometimes of 
such great prominence as to mask the nature of the original disease. 
Vomiting without any obvious cause, in children of tender age, 
should always arouse suspicion of serious brain trouble. Adults 
suffering from brain tumors are occasionally afflicted with gastric 
derangements of such great severity, especially nausea and vomiting, 
that the primary cause may remain unsuspected for a long time. 

Cerebral Breathing. By this is understood an irregular panting or 
noisy respiration. It is usually associated with a jerky, rapid pulse. 
This symptom forebodes danger, as it points to the implication of 
important nerve centers. The so-called " Cheyne-Stokes " respira- 
tion is an aggravated form of cerebral breathing. It is marked by 
an alternating series of exceedingly rapid and slow respiratory 
movements. 

The Tache Cerebral is a test of the cutaneous circulation. On 
passing the finger quickly over a part of the skin (for which purpose 
one of the inguinal regions is usually selected), a red streak will 
appear upon its removal. This redness is comparatively slow in dis- 
appearing when the circulation is depressed, as it often happens in 
cases of acute brain disease. 

Eye Symptoms. Abnormal sensitiveness to light (photophobia) 
occurs in hyperemia and inflammation of the brain and its mem- 
branes. Flashes of light, iridic colors and spectra, dimness of sight 
(amblyopia), double vision (diplopia), total blindness (amaurosis), 
and other disturbances of the organ of vision, are not uncommon in 
cerebral affections; but these ocular symptoms must not be con- 
founded with analogous conditions of the eye dependent on local 
causes. 

Pupillary Changes. The clinical significance of pupillary changes 
can only be adequately appreciated if the reflex mechanism regu- 
lating the movements of the iris be properly understood. The size 
of the pupil under normal conditions is determined by the quantity 
of light that enters the eye. So long as there exists but the feeblest 
sensibility to light, the pupillary reaction will take place, whether 
the light acts upon one or both of the retina. It must be remembered 
that the stimulus of light exciting the retina is propagated by both 
optic tracts (on account of the semi-decussation at the chiasm), first 
to the corpora quadrigemina and then to the nucleus of the motor 



GENERAL SYMPTOMATOLOGY OF NERVOUS DISEASES. 27 

oculi nerve. Some of the branches of this nerve transmit the impulse 
to both irides, which contract to an equal degree. 

Inequality of the pupils occurs : 1. When any one of the integral parts 
of this reflex mechanism becomes disturbed in its function. Let us 
suppose that on illuminating the right eye, its pupil fails to contract, 
but that the pupil of the left eye does; it is certain that the optic nerve 
of the right eye is sound, for otherwise the pupil of the left eye would 
not contract. The want of contraction in the right eye must either 
depend upon some local cause that interferes with the movements of 
the iris, or the corresponding branch of the right motor oculi is para- 
lyzed. If both pupils react to light in cases of total blindness, as in 
ursemic amaurosis, it must be concluded that the blindness is caused 
by an interruption in the course of the nerve fibres that convey the 
visual sensation to the higher centers. 2. Pupillary changes are 
known to be also influenced by the act of accommodation, or, rather, 
the grade of convergence. The pupils contract when they look at 
near, and dilate when they look at distant, objects. The pupil is 
dilated and immovable from paralysis of the peripheral branches of 
the motor oculi. This is frequently observed in brain lesions that 
involve the nucleus of this nerve. Unilateral dilatation and immo- 
bility of the pupil is characteristic of syphilis. 3. A third source of 
abnormal action of the pupils must be sought for in morbid con- 
ditions of the sympathetic. Experiments show that irritation of the 
cervical sympathetic causes dilatation; its division, contraction of 
the pupils. The fibres which act as afferent nerves can be traced 
to the medulla oblongata and to the cervical region of the spinal 
cord, from whence they emerge and connect with the sympathetic 
that sends afferent fibres to the iris. Dilated pupils occurring in 
hemicrania, nephritic colic, and in children troubled with worms, are 
examples of irritation of the sympathetic. 4. Dilatation of the 
pupils is a constant symptom of chronic hydrocephalus and epilepsy, 
and is frequently observed in brain tumors. The best test of 
mydriasis depending either upon irritation or paralysis of the sym- 
pathetic, is the application to the eye of a weak solution of atropia. 
In the former case the pupils greatly enlarge, while in the latter they 
hardly show any increase of dilatation. 

Spinal Paralysis and Associated Symptoms. Bilateral paralysis, or 
paraplegia, is typical of injury and organic disease of the spinal cord. 
The term paraplegia is usually applied to paralysis of both lower 



28 MANUAL OF NERVOUS DISEASES. 

extremities ; but it must be understood that in lesions of the cervical 
region of the cord, the upper extremities are also affected. Accord- 
ing to the experiments of Brown-Sequard, section of one-half of the 
spinal cord produces motor paralysis, and heightened sensibility on 
the side of the injury and anaesthesia on the opposite or uninjured 
side. The extent of spinal paralysis varies with the height at which 
the lesion is situated, and is proportionate in intensity to the amount 
of tissue involved. 

The sphincters are liable to be seriously affected in every form 
of spinal paralysis, and the virile powers are weakened or finally 
abolished. Ischuria or incontinence of urine in the course of chronic 
paraplegia, constitutes an ominous symptom, as it leads to the develop- 
ment of cystitis. Elevation of temperature is occasionally observed 
in recent cases of spinal paralysis; but subsequently it falls below the 
normal range. This symptom is referable to disturbance of the vaso- 
motor nerves which are known to pass out of the vertebral canal in 
company with the anterior nerve-roots. Keflex excitability may be 
either increased or diminished. It is increased when the injury is 
situated below the reflex arc, and diminished when situated above. 
Eeflexes cannot be excited when the sensitive fibres are disconnected 
from their corresponding motor centers. Atrophy of the paralyzed 
muscles is not common in ordinary myelitis ; and if it occurs, usually 
in connection with deterioration of the electric reaction, it must be 
attributed to progressive degeneration of the spinal cord. 

Peripheral Paralysis, The principal causes of peripheral paralysis 
in the order of frequency, are injuries to nerves, acute and chronic 
neuritis, rheumatic, toxic and infectious influences, syphilis and 
ischaemia. The changes in injuries of the nerves have been well 
studied in animals. After section of a nerve-trunk, all the muscles 
to which its fibres are distributed become paralyzed. The nerve 
below the seat of injury undergoes a process of degeneration, and the 
muscles waste. Kegeneration of the divided nerve may take place 
when the cut ends are not too far apart. Compression of nerve- 
trunks and roots resulting from tumors, diseased bones and abscesses, 
produce a similar change in the nerve fibre. The paralysis due to 
rheumatic influences and the diphtheric poison presents all the peri- 
pheral characteristics. Among them none is of more significance 
than the abnormal electric reaction of the paralyzed nerves and 
muscles, which corresponds with the more or less degenerative 



GENERAL SYMPTOMATOLOGY OF NERVOUS DISEASES. 2^ 

changes they have undergone. It is singular that the paralyzed 
muscles may regain their power to respond to voluntary impulses 
although electric stimulation is still incapable of exciting con- 
tractions. Besides these peculiarities of electric reaction, it is of 
diagnostic importance to remember that peripheral paralysis seldom 
assumes the hemiplegic or paraplegic type. It may happen that in 
injury or disease of the cauda equina, the paralysis will present the 
paraplegic character ; but the extent of the paralysis, owing to the 
limited nerve distribution, is much less than in spinal disease. Vaso- 
motor changes and muscular atrophy are the usual concomitants of 
peripheral paralysis. 

Hyperkenesia. Motor disturbances of an irritative nature are char- 
acterized by excessive or irregular movements. The special forms 
comprise convulsions, cramps, choreic movements, athetosis, tremor 
and contractures. 

Convulsions. A paroxysm of convulsions or spasms consists of a 
succession of involuntary muscular contractions. Spasms are said to 
be clonic when the alternate contraction and relaxation of muscles 
produce jerky movements. Tonic spasms are distinguished by a 
greater rapidity in the recurrence of the contractions, so that the 
muscular fibres appear to be in a constant state of rigidity. The 
latter variety of spasms is relatively of a more dangerous character, 
as the exciting cause is more persistent. This is well exemplified in 
tetanus. 

Cramps are painful contractions. The gastrocnemii, and among 
the involuntary muscles, those of the intestines, are particularly 
liable to be thus affected. 

Choreic Movements are marked by an irregular impulsive action of 
groups of muscles. Volition has only a partial command over the 
movements, which constantly tend to diverge from the intended 
direction. 

Involuntary Rhythmical movements, as first described by Ham- 
mond under the name of athetosis, are occasionally observed in 
organic affections of the central nervous system. 

Tremor essentially consists of contractions' and relaxations affect- 
ing small bundles of muscular fibres, which occur with such great 



30 MANUAL OF NEKVOTJS DISEASES. 

rapidity that one set of fibres begins to contract while another set is 
still relaxed. This morbid phenomenon is exhibited in animals 
whose voluntary control over a muscle has been destroyed by division 
of its motor nerve. Tremor in the human subject appears to be due 
to an analogous cause. It is frequently observed in elderly persons 
and inebriates, in wasting palsy and in atrophy of muscles from lead 
poisoning. Tremor is the leading symptom in paralysis agitans, and 
multiple sclerosis of the brain and spinal cord. 

Contracture means a permanent shortening of muscles. Paralyzed 
limbs are liable to be affected in this manner, and tend to become 
distorted in consequence. 



CHAPTEE III. 
MEDICAL ELECTRICITY. 

The electric currents in use at present for medical purposes are : 

1. The Galvanic or Constant Current. 

2. The Faradic or Interrupted Current. 

3. Static Electricity. 

Electro- Physics. As a preliminary I shall refer to a few elemen- 
tary facts in electro-physics. The source of galvanic electricity 
consists of the contact of heterogeneous metals which are submitted to 
chemical action. The simplest arrangement for generating this form 
of electricity is a combination of a zinc and copper plate, which are 
dipped into a glass vessel filled with dilute sulphuric acid. To each 
of the plates outside of the fluid a copper wire is attached, and, as 
soon as these wires are joined, the electricity which accumulated at 
the extremity of each plate begins to circulate in the connecting 
wires. The current of electricity thus established continues until 
the metal plates are completely oxidized. Such a contrivance is 
named an element or cell. The combination of a number of such 
elements, arranged in a series of alternate plates of copper and zinc, 
or carbon and zinc, constitutes a battery. 

It is understood that the plates at each end of a series are always 
composed of dissimilar metals. 

The direction of the current inside of the cell is from the zinc to 
the copper, hence outside of the cell the electricity flows from the 
wire connected with the copper to the wire attached to the zinc. It 
has been agreed to name the terminal of the wire connected with the 
copper the positive pole or anode, and that connected with the zinc 
the negative pole or kathode. If the human body be interposed 
between the extremities of the poles, then the current enters at the 
positive and passes out at the negative pole. 

Electro-Motive Force. The work which a quantity of electricity 
can perform is named its electro-motive force. This working capacity 



32 MANUAL OF NERVOUS DISEASES. 

of a current is influenced in a definite manner by the resistance it 
meets in its passage. There are two sources of such a resistance — the 
' resistance in the battery itself (the fluid, connecting wires), named 
the "specific resistance," and the resistance offered by the interposi- 
tion of any outside substance, say the human body, named the 
"external resistance." These conditions regulate the strength of a 
current. Thus, if we represent the current strength by G, its electro- 
motive force by E, and the specific resistance by R, then we have 

r> 

(7=-^. If we make E equal to 5 and R equal to 100, then 

tfzzz-^-zz^ . It is apparent that we cannot increase the strength of 
100 20 

a current by multiplying the number of elements, since for each in- 
crease of the electro-motive force we get a proportional increase of re- 

5 1 

sistance. For instance, if we use 2 elements we have (7=^ X 2=^- 

and obviously with a like result for any greater number of elements. 
It is different when the external resistance is very great in comparison 
to the specific resistance. This occurs in practice when the human 
body or any of its parts is interposed. Giving the same value as 
above to E and R, let us call R! the external resistance and say it is 
equal to 1000, we then have the equation 

5 5 1 

0=Z R 100 + .fl'1000 = 1100 = 220* 

If we now use two elements, then 0= mo ^ im =4" The 

strength of the current is thus nearly doubled, for the external resist- 
ance is the same for any greater number of elements than one. From 
this it follows that the strength of a current is in direct proportion to 
its electro-motive force and in inverse proportion to its resistance. 
This is " Ohm's Law," which may be thus formulated : " The strength 
of a current is proportionate to its electro-motive force divided by the 
resistance." 

Electric Units. Practical electricians have introduced certain 
technical terms which express with great precision the strength of a 
current. It would answer no useful purpose to enumerate them, and 
it is not within the scope of this work to enter into a detailed account 
of this subject. 




Fig. 5. 



This diagram is intended to illustrate the diffusion of the current throughout 
the arm, irrespective of the points of application of the electrodes. It also 
illustrates the greatest density of the current in the immediate vicinity of both 
electrodes of equal size, which are placed over a nerve (ulnar). The inactive 
rays of the current are marked by dotted lines ; the shaded parts indicate the 
regions of greatest density. 



MEDICAL ELECTRICITY. 



33 



Density of a Current In order to form a clear conception of the 
density of a current, let it be supposed that an electric current con- 
sists of a bundle of parallel rays. It is obvious that the strength of 
the current will vary with the number of rays, and that it will be the 
greatest in any transverse section of such a collection of rays. Now 
each of the terminals of a current contains all the rays where it is 
applied to a part of the human body, and necessarily exerts there its 
greatest force. This condition of the strength of a current in relation 
to a transverse section of its conductor is named its density. It is 
apparent that the density must be the greatest in the straight line 
between the two electrodes which transmit the current into the body, 
it being the shortest route of the current where it meets the least 
resistance. All the other rays from pole to pole must lose in density 
in proportion to the length of their circuitous course. Fig. V. 

The Conducting Power of Organic Tissues. The inequality of the 
conducting power among the component parts of the human body 
also influences the distribution of the current, the resistance it meets 
being greater or less in the different tissues through which it passes. 
Muscles and nerves are the best conductors of electricity among all 
animal tissues. The greatest resistance is offered by the epidermis, 
though it varies to a great extent in different individuals, and in 
different parts of the cutaneous surface in the same individual. The 
following table, according to the investigations of Prof. Erb, shows 
the practical importance of paying attention to this subject : 



Temples, 


; 40° 


Cheeks, ...... 


. 50 


Sides of Neck, . 


. 35 


Shoulder Blades, 


. 20 


Anterior Surface of Thighs, . 


. 3 


Popliteal Space, 


. 26 


Anterior Surface of Upper Arms, . 


. 25 


Outer Surface of Upper Arms, 


. 22 


Palms of Hands, . . . . . 


. 20 



Rheophores; Electrodes. The conducting cords, or rheophores, as 
they are called, are attached to the battery and the handles of elec- 
trodes by pins or screws. They should be kept in good order and 
their contact well secured to prevent failure of electrisation. Much 
stress is laid, by experienced observers, on the choice of the proper 



34 MANUAL OF NERVOUS DISEASES. 

material for covering the disks of electrodes. Flannel or wash leather 
enclosing a layer of fine sponge is now preferred. Brass sponge 
holders are objectionable, they are advantageously replaced by wooden 
cups or carbon plates. Small electrodes serve best for exploration of 
motor points, and application of the current to trunks of nerves and 
small muscles. The medium size is adapted for large muscles. The 
large electrode is used for application to the spine and general 
electrisation. Electrodes of various shapes and designs to answer 
particular purposes are supplied by manufacturers. 

Batteries. 

Among portable galvanic batteries which are offered for sale, there 
is only a choice of evils. In respect to the constancy of the current, 
which is a matter of prime importance, they are all good enough for 
practical purposes, but on the score of portability they fail to fulfil 
the necessary requisites. The Kidder and the Fleming batteries are 
improvements of Stohrer's apparatus. A medical Leclanche, although 
more expensive, is generally preferred. 

Faradic Current. Faraday's discovery that a galvanic current, 
like magnetism, induces new currents in neighboring conductors, has 
been utilized in the construction of an apparatus which renders such 
currents of induction available for medical purposes. All the bat- 
teries in use which generate the faradic current are modifications of 
the sledge apparatus devised by Du Bois Eaymond. The ordinary 
faradic battery consists of a short coil of thick wire wound around a 
wooden cylinder, and connected by one extremity with one of the 
poles of a galvanic cell, and by the other with the automatic inter- 
rupter. The current which generates in the cell, and is interrupted 
by the alternate opening and closing of the circuit, develops the 
induction current in the coil. Within the center of this coil are rods 
of soft iron, which, on becoming magnetized, intensify the current in 
the spiral. A secondary coil consisting of thin and longer wire, and 
unconnected with the rest of the apparatus, slides over the primary 
coil. The rheophores are attached to the extremities of this coil. 
This current takes an opposite direction to the primary when the 
circuit is closed through the action of the hammer, and the same 
direction when it is opened. There is no specific difference in the 
action of the two currents, but the effect of the secondary spiral 
increases the more it is slided over the primary. The strength of 



MEDICAL ELECTRICITY. 35 

either current can be lowered when the iron cores are drawn out. 
The arrangement for increasing or diminishing the strength of the 
current differs in different apparatus. 

The faradic current, in comparison with the galvanic, possesses 
inferior chemical or electrolytic power, but it surpasses in the energy 
of its physiological effects. This is due to the abrupt development 
and brief duration of the induction currents. The negative pole of a 
faradic battery can be distinguished from the positive pole by its 
more vigorous action on the motor and sensory nerves. 

Electro-Physiology. 

Eledrotonus. When a galvanic current passes continuously through 
a motor nerve no visible effect is produced, but a contraction of the 
corresponding muscle immediately occurs as soon as the circuit is 
opened. A contraction again occurs at the moment when the circuit 
is closed. By alternately lifting and replacing one of the electrodes, 
or by using the interrupter which is attached to every galvanic bat- 
tery, such a closing and opening of the circuit is effected. Although 
the nervous impulse, excited by a continuous current, is only recog- 
nizable when there is a make or break of the circuit, nevertheless a 
change takes place in the condition of the nerve. This consists in an 
altered state of excitability of the nerve, and such a nerve is then said 
to be in a condition of eledrotonus. This modification of excitability 
is demonstrated by experiment. It has been further ascertained 
that the excitability is heightened at the point where the kathode 
lies over the nerve (katelectrotonus), and lowered at the point 
of contact with the anode (anelectrotonus). It appears, therefore, 
that the physiological effects of the two poles differ in relation to 
the condition of excitability which they produce. But they also differ 
in the circumstances attending the contractions. The admirable 
experimentation of Pflueger on a dissected nerve resulted in the 
establishment of the normal formula of contractions. He found 
that both the apparition and energy of the contractions are influenced 
by the polarization as well as the duration of the current. In the 
human subject, however, where different conditions prevail, a different 
formula of normal contractions obtains, but which is of general 
application in practice. The experiments that illustrate these " laws 
of contractions " may be briefly described as follows : A current of 
minimal strength is used at first, and the anode, to which a large 



36 MANUAL OF NERVOUS DISEASES. 

electrode is attached, is placed on a distant part of the body, and 
the smaller electrode of the kathode is brought in contact with the 
surface immediately over the nerve (ulnar or peroneal). If the 
current be of sufficient strength, a contraction ensues, i. e. there will 
be a kathodic closing contraction ; any other polarized current will 
fail to produce a contraction. The strength of the current must 
now be sufficiently increased to elicit an anodic closing or an anodic 
opening contraction. A yet stronger current is requisite to produce 
a kathodic opening contraction. A healthy nerve will, therefore, 
respond by a contraction in the following order, according to the 
strength of the current : 

1. Weak current, KGG. 

2. Medium, AUG, AOG. 

3. Strong, KOG. 

Explanation of letters and symbols : 

K— Kathode. 

A rz Anode. 

C — Contraction. 

C — Closing or making. 

— Opening or breaking. 
/ // /// = Signs of intensification. 
< > zz Crescendo, diminuendo. 

The laws of electric contraction in muscles differ in no essential 
particulars from those of the motor nerves. The response of a 
muscle to the action of the current is named " the electro-muscular 
contractility," the sensation experienced during electric contraction 
is named "the electro- cutaneous sensibility." No effect is produced 
when the current is thrown transversely through a muscle. 

Physiological Effects of the Current in Different Organs. 

A sensory nerve responds by a peculiar sensation, which changes 
into pain when the intensity of the current is increased. The effect 
is the same whether the nerve be stimulated in any part of its course, 
or at its peripheral termination. Galvanization causes a stinging or 
burning sensation; faradization a feeling of tingling with every shock. 
The faradic current barely affects the special senses, but they promptly 
respond to the galvanic current. On applying the electrodes of a 
weak galvanic current to the temples or cheeks, the sensation of a 



MEDICAL ELECTRICITY. 37 

flash of light is produced. Of much greater theoretical interest are 
the effects of the current when directed to the auditory nerve. Accord- 
ing to the law of normal reactions of this nerve, as formulated by 
Brenner, auditory sensations of the nature of ringing, hissing or 
whistling are experienced, when a kathodic make-current or an anodic 
break-current is applied to the ear. It is certainly remarkable that 
all the phases of polar excitation characteristic of a motor nerve 
are reproduced on galvanizing the acoustic nerve. 

Galvanization of the tongue causes a peculiar metallic taste, which 
is also experienced when the electrodes are applied to the cheeks and 
nape of the neck. 

Electric stimulation does not appear to influence the sense of smell. 

Galvanization of the Sympathetic. The possibility of so localizing 
a current that it may act directly on the cervical sympathetic and its 
ganglia, is doubted by many eminent observers. It is recommended 
to apply the anode to the part intervening between the mastoid pro- 
cess and the ascending ramus of the inferior maxillary bone, and the 
kathode to the sixth or seventh cervical vertebra, or to the sternum. 
In view of the uncertainty overhanging the entire subject of " galvan- 
ization of the sympathetic," the following statement regarding its 
effects can only be provisionally accepted : 

1. The arterial blood pressure is diminished as indicated by the 
slowing of the pulse. 

2. The bodily temperature is occasionally increased and sometimes 
attended by sweating. 

The Brain. Electric stimulation of the brain was formerly 
thought to give rise to no particular phenomena, until Hitzig and 
Ferrier demonstrated that certain areas of the cortex responded in 
the manner described in a previous chapter. 

Galvanization of the head excites some of the special senses and 
causes drowsiness and vertigo. Strong currents produce faintness, 
convulsions, and sometimes nausea and vomiting. Dizziness invari- 
ably follows when the current is thrown into the head in a transverse 
direction. 

The Spinal Oorol. Therapeutical observations leave no room for 
doubt that the spinal cord is accessible to the action of the electric 
current. Large sponges should be selected and applied to the spinal 
column at a considerable distance apart. 



38 MANUAL OF NERVOUS DISEASES. 

Internal Organs. Only those internal organs which contain mus- 
cular tissue respond to electric excitation. Striped muscles react 
more strongly than unstriped. 

Electro-Diagnosis. 

Electrical investigations greatly assist the recognition of many 
diseases of the nervous system. Much experience and familiarity 
with the sources of fallacy, as in analogous methods of physical 
diagnosis, are requisite to derive advantage from the results of the 
exploration. We have seen that healthy motor nerves and muscles 
react in accordance with the formula of the laws of contractions. 
Certain deviations from this normal order of contractions are found 
to correspond with nutritive alterations in the neuro-muscular appa- 
ratus. These irregularities consist of quantitative and qualitative 
changes. The quantitative changes comprise : 1. A difference in the 
amplitude of the contraction, i. e. the contractions manifest either 
an exaltation or diminution of energy — the electric stimulus may 
elicit a well-defined, vigorous jerk, or a sluggish, long-drawn wave 
of contraction. 2. The qualitative change is manifested by an 
abnormal formula of contractions. Thus, in place of KCC, which 
should be the only polarized contraction according to the normal 
formula, there may also appear ACQ and AOC, or the AOC is equal 
to KCG (AOC=:KCC^). It may even happen that KOC appears 
early. Another phenomenon indicating an abnormal reaction is this, 
that a motor nerve responds to a galvano make and break-current, 
whilst the farado-contractility is not elicited. At the same time, the 
normal chronology of polar contractions is altered. 

JSTow, whenever a part of the nervo- muscular apparatus shows any 
of these abnormal reactions, it may be safely concluded that its tissue 
has undergone some nutritive or histological change. This abnormal 
reaction is named the " reaction of degeneration " (RD). The patho- 
logical conditions of the nervous system which give rise to RD 
include morbid alterations of the grey matter of the anterior horns 
of the spinal cord, and the channels of trophic influences which 
proceed from these centers, namely, motor nerves. 

The special diseases in which RD has been uniformly observed are 
infantile spinal paralysis, progressive muscular atrophy, lead poisoning, 
and severe forms of rheumatic paralysis. 

It must be borne in mind that wasted muscles, due to a local or 



MOTOR POINTS. 



M. frontalis 



Up & 



er branch of 
acial nerve 



M. orbic. palpeb. 

Nasal muscles 

M. zigomatici 

M. orbic. oris 

Middle branch of 
facial nerve 

M. avator menti ) 
M. quad, menti > 
M. triang. menti ) 

Hypoglossal nerve 
M. platysm myoid 

Inferior branch of 
the facial nerve 

M. omohyoides 




Region of the central 
convolution 



Region of the third 

frontal convolution 

(Brocar) 

Upper branch of the 

facial nerve 
Trunk of facial nerve 



Inferior branch of 
facial nerve 

M. sterno cleido- 
mastoides 

Accessory nerve 



Phrenic nerve Supraclavicular point Brachial plexus 
(Erb's point), M. deltoid, 
biceps, brachial internus 
and supinator longus. 

Fig. 6 (Erb). 



Branch of the median nerve 
for the pronator teres 

Palmaris longus 



Flexor carpi ulnaris 



Plexor sublimis digitorum 
(middle and ring fingers) 

Ulnar nerve .. 
Plexor sublimis digitorum „, 
(index and little fingers) 



Deep branch of the ulnar nerve -• 

Palmaris brevis -• 

Abductor minimi digitorum - 

Flexor brevis minimi digiti "' 



Lumbricalis (2, 3 and 4) 




Flexor carpi radialis 
Flexor profundus digitorum 

Flexor sublimis digitorum 



Flexor longus pollicis 
Median nerve 



Abductor pollicis 
Opponens pollicis 
Flexor brevis pollicis 
Abductor pollicis 
Lumbricalis (1st) 



Fig. 7.— Ziemssen's Motor Points. 



Supinator longus 
Extensor carpi radialis longior 

Extensor carpi radialis brevior 



Extensor communis digitorum 



Extensor indicis 
Extensor indicis and extensor 
ossis metacarpi pollicis 

Extensor ossis meta- 
carpi pollicis ? 



Extensor primi internodii 
pollicis 
Flexor longus pollicis 



Dorsal interossii < 




Extensor carpi ulnaris 
Extensor minimi digiti 

Extensor indicis 

Extensor secundi internodii 
pollicis 

• Abductor minimi digiti 
■• Dorsal interosseus (4) 



Fig. 8.— Ziemssen's Motor Points. 



Inferior gluteal nerve 
for glutius maximus " 

Great sciatic nerve — 

Long bead of biceps " 

Short head of biceps '' 



Posterior tibial nerve 
Peroneal nerve 

Gastrocnemeus 
(external head) 

Soleus 




Abductor magnus 

Semitendonosus 

Semimembranosus 



Gastrocnemeus 
(internal head) 



Fig. 9. — Ziemssen's Motor Points. 



Anterior crural nerve 



Obdurator nerve ■ «v« 

Sartorius *; 

Abductor longus p 

Branch of crural nerve to *""' 
quadriceps extensor femoris 

Crureus ""' 

Branch of crural nerve -" 
to vastus externus 




Tensor facial femoris (branch 
of superior gluteal nerve) 



Tensor facial femoris (branch 
of crural nerve) 



Rectus femoris 



Vastus externus 



Vastus externus 



Fig. 10.— Ziemssen's Motor Points. 



Peronetis longus 
Tibialis anticus 




#-.m Peroneal nerve 

V A Gastrocnemeus 

\ \ 

v \ -V— - Soleus 

"*!» ' External communis 
digitorum longus 

m ^$Wt~"' P eroneus brevis 
/ M— Soleus 



Extensor longus pollicis — 



- Flexor longus pollicis 



Branch of peroneal nerve for 
extensor brevis digitorum 



Dorsal interossii< — 




1 — Extensor brevis digitorum 
Abductor minimi digiti 



Fig. 11. — Ziemssen's Motor Points. 



Gastrocnemeus 

(internal head) 

Solens 



Flexor communis 
digitorum longus 



Posterior tibial nerve ■— - 



Abductor pollicis ■"' 




Fig. 12. — Ziemssen's Motor Points. 



MEDICAL ELECTRICITY. 39 

rather to a peripheral cause, also show a decrease or complete failure 
of electric reaction. 

Motor Points, By the indirect method of electric stimulation, not 
only a large number of muscles supplied by a nerve trunk can be 
simultaneously thrown into contractions, but also deep-seated muscles 
can thus be reached. To accomplish this purpose, it is necessary to 
determine the locality of the accessible motor nerves, or rather the 
so-called " motor points." 

The annexed figures showing these motor points are reproduced from 
the works of Ziemsen and Erb. 

Electro-Therapy. 

Very little of a positive character can be advanced in explana- 
tion of the modus operandi of electricity as a remedial agent. In 
fact, its therapeutical reputation rests for the most part on empi- 
rical grounds. To say that the curative properties of the electric 
current depend upon the stimulant effect it exerts on nerves and 
muscles, conveys but a limited conception of its action. All that 
experience teaches is the simple fact that certain pathological condi- 
tions are modified under the influence of electricity in some undeter- 
mined manner. Remak ascribes this influence to the catalytic action 
of the current affecting the vaso-motor and trophic nerves; Erb, to 
its electrolytic effect on the molecular and chemical changes of the 
organic tissues. There is reason to conclude, from a large number 
of observations, that the electrotonic effect of the current is of wide 
application in the treatment of diseases requiring an energetic nervous 
excitation. The "refreshing effect " of electricity in tired-out muscles 
is probably of that nature. 

The Polar Method. Eminent observers maintain that the influence 
of the current is determined by its direction. A current is said to be 
" descending " when it flows from the center to the periphery, i. e. 
when the kathode is nearest to the muscle ; and " ascending " when 
the current flows in the opposite direction, i. e. when the anode is 
nearest to the muscle. The balance of opinion appears to incline in 
favor of the " polar method." This method answers every practical 
purpose, and besides allows the choice of either the excitant effect of 
the negative pole, or the sedative influence of the positive pole. It 
offers also the decided advantage of localizing a current of the required 



40 MANUAL OF NERVOUS DISEASES. 

density. The latter consideration is of no little moment, for the rule 
in electro-therapy is to apply the current in loco morbi, and to inten- 
sify its action at " the point of election." We have seen that the 
maximum strength of a current is at the point of its greatest density. 
In sending a current into the body, several ways are offered by which 
a current of sufficient density can be transmitted to the affected part. 
If it be desired to apply the current to a part near the surface of the 
body, it is advisable to select medium electrodes, and place them 
close to each other. This procedure is well adapted to the electrisa- 
tion of large muscles. If a part lies deeper, a small " active " elec- 
trode is placed as near to it as possible, and the " indifferent " electrode 
of larger size is applied to a distant part. When a very deeply seated 
organ is intended to be stimulated, as, for instance, the spinal cord, 
the rule is to select electrodes of very large size, which should be 
placed wide apart from each other. In reference to the choice of the 
poles, it is best to follow the advice of De Watteville : " Whenever 
the expected result does not follow the influence of the theoretically 
indicated pole, the contrary pole is to be tried." 

Practical Remarks. No special rules can be laid down in refer- 
ence to the choice of currents. The therapeutical effect of either is 
frequently the same in many cases. The galvanic current is superior 
to the faradic in diseases due to nutritive changes and in disorders 
like hyperesthesia, neuralgia and spasms, which result from hyper- 
excitability. Different methods of applying the current are advan- 
tageously used in certain diseases. There is the "stabile" current, 
which signifies undisturbed electrisation; the "labile" current, which 
means repeated removal and replacement of one of the electrodes. 
Frequent reverses of the poles — the so-called " Voltaic alternatives''* — 
intensify the continuous current. Dabbing an electrode on the 
surface is another way of applying the labile current. 

An overdose of electricity always does harm. There is no better 
way of becoming familiar with the different strengths of the current 
than to practice on one's self. The faradic current is preferable for 
exciting muscular contractions and to stimulate the skin. It is, 
therefore, much employed in motor and sensory paralysis. 

The pain on electrising the face is mitigated by dusting the part 
with toilet powder. In order to avoid the pain which is caused on 
using a strong galvanic current, it is advisable to switch in the 
desired number of elements, a few at a time, and to exclude them in 



MEDICAL ELECTRICITY. 41 

the same manner before the removal of the sponges. A firm, steady 
pressure on the electrodes produces less pain than holding them 
lightly to the skin. 

Dry sponges or the uncovered disks, and, better still, the electric 
brush when powerful stimulation is indicated, suit applications to 
the skin. To act upon motor nerves and muscles wet spouges should 
be used. Sometimes there is little or no response to the galvanic 
current until the sponges and the skin are well moistened with warm 
water to which salt has been added. 

Daily sittings are required where the cumulative effect of the 
stimulation is desired. The duration of a sitting varies, according to 
circumstances, from two to fifteen minutes. General electrisation 
should occupy at least twenty minutes. 

Batteries require constant care to keep them in good working order. 
In most instances, when an induction apparatus loses its force, it is 
due to the rust which collects on the hammer. The fluid requires 
frequent renewal. Defect in the different connections weakens or 
arrests the current. 

General Galvanisation. This manner of applying the current is 
intended to influence the nerve centers. The positive pole is passed 
from the forehead and vertex down the whole length of the spinal 
column, while the negative pole is held to the pit of the stomach or 
the sacrum. Care must be taken to graduate the strength of the 
current. A weak current should be applied to the head for a few 
minutes. General galvanisation has been found beneficial in neuras- 
thenia, insomnia and analogous functional disturbances of a cerebral 
character. 

General Faradisation. This practice was introduced by Drs. 
Beard and Eockwell, of Xew York. The patient is seated on a low 
stool, his feet resting on a large electrode to which the negative pole 
is attached. With the other electrode every part of the body from 
the head to the soles of the feet is electrised. Unnecessary pain is 
avoided by the regulation of the strength of the current. General 
faradisation exerts an electrotonic effect, due to its action on the 
muscles and the circulation. Benefit is derived from its use in states 
of general debility from constitutional causes. 

The Electric Bath. One of the poles of a strong induction current 
is placed in the bath tub, wherein the patient is immersed above his 
shoulders. The other pole is applied to different parts of the body. 



42 MANUAL OF NERVOUS DISEASES. 

The addition of salt or acid to the water rather lessens than favors 
the penetration of the current. The electric bath is only another 
form of general faradisation. 

The Electric Hand. This method is chosen for stimulating the 
face of timid or sensitive persons. One sponge is held by the patient, 
the other by the physician. The latter places the palm of his free 
hand upon the well-dried forehead of the patient. Moistening the 
hand or fingers has a more energetic effect. „ 



CHAPTEE IV. 

SPECIAL PATHOLOGY AND THERAPEUTICS OF 
NERVOUS DISEASES. 

Neuralgia. 

Neuralgia denotes a characteristic pain which results from a 
variety of causes. Although for this reason it should be viewed 
in the light of a symptom, still there are weighty considerations 
that vindicate for it the claims of an individual disorder. In 
the first place, the clinical features of neuralgia indicate a peculiar 
morbid condition of sensibility, frequently of an obscure origin, and 
then pain is always an object of treatment. Neuralgic pains 
are limited to definite nerve paths, and spontaneously recur in 
paroxysms of great vehemence. Patients usually describe the pain in 
the strongest language. It is darting, shooting, lancinating, etc., and 
marked by remissions and exacerbations. Complete intermissions are 
typical of neuralgia. The existence of painful spots in the course of 
the affected nerve is another peculiarity of neuralgia, though occa- 
sionally they are absent. These " puncta dolorosa " are usually found 
in places where the nerves pass through bony canals, or penetrate the 
fasciae of muscles. During the paroxysm it is not unusual for the 
pain to radiate to other branches of the same nerve trunk. In more 
rare instances, the pain appears to be translated to the opposite 
symmetrical nerve, and sometimes to nerves in remote parts of the body. 

Complications. These are principally due to associated motor and 
vaso-motor disturbances. In the neuralgia of mixed nerves, as in 
sciatica, the same morbid cause which gives rise to the pain may 
simultaneously induce motor irritation in the forms of fibrillary 
movements and cramps. After the subsidence of the latter, some 
degree of muscular weakness is often noticed. But the motor irrita- 
tion is sometimes of a reflex character. This is well exemplified by 
the convulsive movements (tic) of the facial muscles in neuralgia of 
the trigeminus. The implication of the vaso-motor nerves is 



44 MANUAL OF NERVOUS DISEASES. 

inferred from the pallor and subsequent redness of the skin and mucous 
membranes. Of the same import are the secretory disturbances 
affecting the saliva, tears and nasal discharge. Trophic disturbances, 
under similar circumstances, cause the appearance of cutaneous erup- 
tions, atrophy of the skin and subcutaneous fat, and the stunted 
growth of the hair and nails. 

Etiology. Heredity constitutes an important etiological factor in 
many cases of neuralgia. This is evident from the frequent occurrence 
of allied neuroses, such as epilepsy, hysteria and convulsive attacks, 
among the members of the same family. It is assumed that some 
congenital abnormality of the nervous system predisposes such 
persons to this class of disorders. 

Age and Sex. Children of a tender age are rarely the subjects of 
neuralgia ; nor is it a common affection in persons past the middle 
period of life ; but elderly people are sometimes afflicted with a most 
terrible form of facial neuralgia, which probably depends upon senile 
changes of the arteries. Neuralgia is most frequent between the 
ages of twenty and forty years. Females suffer oftener from it than 
males. 

Anmmia. General anaemia and the chlorotic diathesis act decidedly 
as predisposing causes of neuralgia. The impoverished state of 
the blood, and the consequent mal-nutrition of the body, weaken 
resistance to the obnoxious influences that favor the development of 
neuralgia. 

Nervousness. This is not the place to discuss the subject of 
nervousness and its aggravated or peculiar manifestations, such as 
hysteria, hypochondriasis, spinal irritation and neurasthenia. It 
suffices to allude here to the common experience that but few 
patients who suffer from any of these disorders are exempt from 
neuralgic pains. The period of puberty in females has a similar 
tendency to develop neuralgia. This must be attributed to the 
profound influences at this epoch of woman's life that particularly 
react upon the nervous system. 

Traumatic and Analogous Causes. Neuralgia from injuries to 
sensory nerves is well illustrated in those instances where the stump 
of an amputated limb becomes the seat of exquisite pain. The irrita- 
tion set up by tumors and diseased bones is frequently followed by 
a like effect. Neuromatous growths, and the so-called "painful 



SPECIAL PATHOLOGY AND THERAPEUTICS. 45 

tubercle," are also sources of local neuralgia. Kheumatic or atmos- 
pheric influences must be charged with causing genuine neuralgia, 
as its occurrence may often be directly traced to exposure to cold and 
dampness. Weir Mitchell describes a form of neuralgia (causalgia), 
resulting from gunshot wounds, which is marked by an unbearable 
pain, not only at the seat of injury, but also in the course of the 
affected nerve trunk. 

Toxic Causes. Neuralgia of a regular periodical type is character- 
istic of malarial influence. The supraorbital branch of the fifth pair 
of nerves is the favorite seat of this form of masked intermittent. 
Nocturnal pains, affecting by preference the scalp and lower extrem- 
ities, suggest the existence of constitutional syphilis. Lead poisoning 
gives rise to peripheral as well as to visceral neuralgia. In a case of 
this kind which came under my observation, the pain was located in 
the forearm, the shoulder and the cervico-occipital region of the 
same side. The neuralgia immediately succeeded an attack of colic. 

Diagnosis. By strictly adhering to the accepted definition of 
neuralgia, much embarrassment in its diagnosis may be avoided. 
The pain of neuralgia is of a remittent or intermittent character, of 
extreme violence, and usually coming on without an assignable cause. 
It is confined to the course of a nerve or involves more or less exten- 
sively the distribution of a nerve trunk. The existence of " painful 
spots " along the affected nerve paths, and especially vaso-motor dis- 
turbances, are of great diagnostic value. Whether a neuralgia is of 
central origin or not, must be decided by the history of the case and 
its concomitant symptoms. 

Treatment. The difficulties encountered in the treatment of neu- 
ralgia relate, principally, either to the obscurity of the seat and nature 
of the irritation, or to our inability to remove the cause in cases where 
it is well understood. A morbid tendency, whether constitutional or 
acquired, that favors the development of neuralgia, frequently opposes 
our best directed efforts for its permanent cure. But, in general, it may 
be said that among all the functional diseases of the nervous system, 
none yield more frequently or readily to therapeutical measures than 
neuralgia. Cases which allow of surgical interference promise satis- 
factory results. Thus foreign bodies and necrosed bones may be 
removed, cicatrices split or excised and neuromatous tumors extirpated. 
Neuralgia occurring at regular periods, whether due to malaria 
or other morbid influences, indicates the administration of quinia or 



46 MANUAL OF NERVOUS DISEASES. 

arsenic. Pains of syphilitic origin are successfully treated by potass. 
iod., or mercury. The former remedy is often found beneficial in 
rheumatic and saturnine neuralgias. Iron has a deserved reputation 
in all varieties of neuralgia which are liable to develop in anaemic and 
chlorotic patients. Of all the different remedies, none stand in higher 
repute in the treatment of every form of neuralgia than opium or its 
preparations ; and next in rank, belladonna, or rather atropia. The 
frequent resort to this class of medicines is due to the necessity of 
adopting a symptomatic treatment in numerous cases. Among the 
many empirical remedies in vogue, there are undoubtedly some that 
do not owe their reputation to mere coincidences. Arsenic, in the 
form of Fowler's solution, commencing with five drops three times a 
day after meals, should always have a fair trial in chronic cases. The 
tinct. of gelsemium sempervirens in doses of fifteen drops, frequently 
repeated until its physiological effects become apparent, seems to be 
of occasional benefit in neuralgia affecting the dental branch of the 
trifacial nerve. Phosphorus and turpentine have sometimes proved 
beneficial in inveterate cases. The latter remedy must be given in 
large doses. 

A systematic course of tonic and supporting treatment is of prime 
importance in all instances of neuralgia traceable to nervous exhaus- 
tion. Sufficient rest and plenty of digestible food constitute here the 
indispensable adjuvants of successful treatment. 

The prompt action of sedative remedies for the relief of neuralgic 
pain can now be readily obtained by the use of the hypodermic syringe. 
This mode of administering morphia and atropia is, therefore, prefer- 
able whenever the patient offers no particular objection. Stimulant 
and anodyne liniments, variously combined, are much employed in the 
lighter forms of neuralgia; but blistering is undoubtedly of superior 
value. For this purpose, the cantharidal collodion is to be recom- 
mended, which can be applied with a brush to any part of the surface. 
Electricity is occasionally of great service. Its remedial effects, 
according to Duchenne, are also observed when the electric brush is 
placed at a short distance from the painful part. The constant cur- 
rent is, however, preferable. Daily applications of from ten to fifteen 
minutes are required. The anode is applied to the painful nerve, and 
the kathode to an indifferent part of the body. Kecent trials of 
nerve-stretching, for the relief of severe and inveterate cases of 
neuralgia, have been followed by a measure of success which justifies 
the adoption of this surgical procedure in appropriate cases. 



SPECIAL PATHOLOGY AND THERAPEUTICS. 47 

Facial Neuralgia. Neuralgia affecting the different divisions of 
the trigeminus is of frequent occurrence. This is especially true of 
the ophthalmic branches. Malaria and atmospheric influences are 
accused of constituting the most common causes of this form of 
neuralgia. The " brow ache " is said to be notoriously common in 
malarial districts. In neuralgia of the head, it is advisable to search 
for stumps of decayed teeth and a crowded wisdom tooth. 

The most constant painful spots in the distribution of the ophthal- 
mic division of the trigeminus are found in the region of the supra- 
orbital notch, on the upper eyelid, the inner angle of the eye and at 
the parietal eminence. In the course of the superior maxillary, a 
focus o*f pain is found at the infra-orbital foramen and another in the 
region of the malar bone. In the inferior maxillary division, it is 
usual to meet with the temporal and the inferior dental puncta 
dolorosa. 

The vaso-motor disturbances, which are particularly common in 
facial neuralgia, consist of strong pulsation of the temporal arteries, 
reddening of the conjunctiva, increased secretion of the lachrymal 
and salivary glands and of the nasal mucous membrane. Motor 
disturbances of a reflex character, involving groups of muscles of the 
affected part of the face, are also frequently noticed in the form of 
spasmodic contractions. (Tic convulsif. Blepharo-spasm.) Severe 
and inveterate cases of facial neuralgia exert an injurious influence 
on the general health in consequence of constant suffering and loss of 
sleep. 

Treatment. Quinia and salicylate of soda in large doses, and, in 
obstinate cases, the persistent use of arsenic, often prove of great effi- 
cacy. Sometimes a combination of morphia and quinia gives excel- 
lent results. From personal experience, I can speak favorably of the 
veratria ointment in cases of moderate intensity. In that exceedingly 
distressing variety of facial neuralgia occurring in elderly people, 
scarcely anything else can be done to afford relief than repeated 
injections of morphia. Much may be expected in well-selected cases 
from potass, iod. The cautious use of the galvanic battery sometimes 
yields surprisingly good results. It is in facial neuralgia that nerve- 
stretching has been most frequently tried with an encouraging degree 
of success. 

Hemicrania ("Migraine" Sick- Headache). This disease is now 
considered an angio-neurosis. A number of its symptoms evidently 



48 MANUAL OF NERVOUS DISEASES. 

result from vaso-motor disturbances. Painful spots are wanting, 
though the scalp is very sensitive to the touch. Only one side of the 
head is affected, and, singularly, it is the left side which suffers in the 
majority of cases. The pain may be chiefly felt in the frontal, 
parietal or occipital region. The onset of an attack is occasionally 
preceded by shuddering, sighing and yawning. Its duration is 
variable, but is rarely prolonged beyond twelve hours. Nausea and 
vomiting frequently supervene, without, however, mitigating the pain. 
There is much nervous depression and a strong inclination to sleep. 

Hemicrania is an affection of frequent occurrence in the female 
sex. It often dates from earlj childhood. Heredity and the period 
of puberty constitute the chief predisposing causes. 

Diagnosis. The clinical history of hemicrania is sufficiently well 
marked to obviate diagnostic difficulties. A first attack of great 
severity may cause embarrassment for a short time. It must be 
distinguished from " clavus hystericus." 

Treatment. Considerable relief is obtained during the violence of 
an attack from the application of cold to the head. Morphia, in the 
form of hypodermic injections, does not allay the pain as promptly as 
it does in true neuralgia. The effervescent citrate of caffein in tea- 
spoonful doses, or bicarbonate of soda in large draughts of hot water, 
will occasionally stop the retching and vomiting. From ten to fifteen 
grains of quinia, promptly administered at the very onset of the 
paroxysm, sometimes succeeds in cutting it short. Guarana in doses 
of fifteen grains, frequently repeated, also deserves a trial. Good 
results may be expected from the inhalation of nitrate of amyl in 
that variety of migraine which appears to be due to spasmodic 
vascular constriction. 

Occipital Neuralgia. The two upper cervical nerves are distributed 
to the whole of the occipital and also partly to the parietal regions. 
Branches of the third and fourth cervical go to the lower portion of 
the cheek, to the side of the neck and to the supra-clavicular region. 
As these nerves are more or less simultaneously involved, it is usual 
to speak of cervico-occipital neuralgia. Care must be taken not to 
confound it with the pain attending caries of the cervical vertebrae. 
Occipital neuralgia is commonly of great severity. The affected parts 
are extremely sensitive, the slightest movement of the head being 
apt to bring on a paroxysm of pain. The most constant painful spot 
is found about the superior portion of the occipital prominence. 



SPECIAL PATHOLOGY AND THERAPEUTICS, 49 

Treatment. Local measures in the form of wet cups, or better 
still, repeated blistering, constitute the most approved treatment. 
The galvanic current of about thirty elements directly applied to the 
parts rarely fails to give relief. Morphia, to allay the violence of the 
pain, cannot easily be dispensed with in severe cases. 

Brachial Neuralgia. This comprises a large group of neuralgias 
which severally affect the cutaneous distribution of the ulnar, the 
median and radial nerves that collectively proceed from the brachial 
plexus. Isolated neuralgias may occur in the shoulder, the scapula, 
the upper arm, the ejbow, the forearm, the wrist, hand and fingers. 
Among the most constant painful spots may be mentioned a point 
where the radial curves around the humerus; and another in the 
course of the same nerve near the wrist. Occasionally an upper 
ulnar point between the olecranon and the internal condyle, and a 
median point at the bend of the elbow, may be detected. 

Motor and trophic disturbances frequently complicate this form of 
neuralgia. The former consist of cramps and twitching of muscles, 
and the latter of cutaneous eruptions near the seat of the pain. 

A rheumatic influence is probably the most common exciting cause 
of the neuralgia. The superficial situation of the radial and ulnar 
nerves exposes them to direct injury. 

An instructive example of the singular complications that some- 
times attend injuries to cutaneous nerves came under my notice at 
the Baltimore City Hospital. The patient, a young Irish woman, 
presented herself with a stiff, painful arm, much swollen at the 
elbow and covered by large blebs resembling pemphigus, which 
extended from the wrist to the shoulder. The house surgeon had 
observed a few black spots near the turn of the radial nerve on the 
upper arm that proved to be the ends of large sewing needles. The 
girl confessed afterwards that she had designedly pushed them in for 
the purpose of being admitted into the hospital. The treatment of 
brachial neuralgia is conducted on the same principles as the fore- 
going variety. 

Dor so- Intercostal Neuralgia. The superficial branches of the 
seventh, eighth and ninth pairs of dorsal nerves, which run in the 
direction of the intercostal spaces, are usually affected in this variety 
of neuralgia. Painful spots are found in the region where these 
nerves emerge from the intervertebral foramina, at the bend of the 
ribs and near the junction of the cartilages and the sternum. 



50 MANUAL OF NERVOUS DISEASES. 

Nervous and anaemic women are exceedingly liable to suffer from a 
neuralgic pain beneath the left mamma. It is often associated with 
spinal tenderness. 

The frequent association of herpes zoster with dorso-intercostal 
neuralgia is an interesting fact, as it points to the neurotic origin of 
the cutaneous eruption. It appears that the source of irritation 
which affects the sensitive fibres also implicates the vaso-motor 
branches distributed to the same region of the body. 

Intercostal neuralgia must not be confounded with pleurodynia. 
This phrase is often used to designate a diffuse pain affecting the 
thoracic walls, which is of a rheumatic or, rather, a myalgic char- 
acter. There seems to be a causal relation between uterine and 
ovarian trouble and intercostal neuralgia. Diseases of the vertebrae 
and spinal cord are frequently attended by a neuralgic pain in the 
dorso-lumbar region and parts of the chest. 

Treatment. Constitutional as well as local treatment is indicated. 
My own experience speaks highly in favor of strapping the parts with 
strips of adhesive plaster, as it is practiced in fracture of the ribs. 
Stimulant liniments are useful in cases of moderate severity. The 
violence and persistence of the pain which often accompanies the 
development of shingles require morphia. The vesicles should not be 
disturbed by friction with ointments. 

Lumbar Neuralgia. The branches of the lumbar plexus are com- 
paratively but seldom the seat of neuralgia. Those parts to which 
the ileo-inguinal, the ileo-hypogastric and the genito-crural nerves 
are distributed are most frequently affected. They comprise the 
back, the mons veneris, the labia, the scrotum, the inner side of the 
upper portion of the thigh and the inner edges of the knee, foot and 
big toe. Neuralgia of the obturator nerve deserves particular atten- 
tion, as it is symptomatic of strangulated hernia within the obturator 
foramen. 

Sciatica. This is one of the most frequent forms of neuralgia. 
The great length of the nerve and its extensive distribution subject it 
to numerous morbid influences, and, in addition, the sacral plexus 
may become involved in intrapelvic diseases. The pain in sciatica is 
usually of great severity, and, as a rule, reaches its maximum of 
intensity at once. A renewal of the pain may at any time be brought 
on by flexion of the limb ; hence the patient instinctively adopts a 
peculiar stiff gait. Sciatica is occasionally complicated with tremor 



SPECIAL PATHOLOGY AND THERAPEUTICS. 51 

and cramps of the affected extremity, and sometimes wasting of the 
muscles is noticed. Hyperesthesia is a constant concomitant, 
though numbness and a furry feeling of the parts may be associated 
with it. 

The painful points are numerous, and some are constantly present. 

A tender spot corresponding to the trunk of the nerve between the 
great trochanter and the tuber ischii is seldom wanting. There is a 
fibular point along the superficial course of the peroneal nerve, and 
an external and internal malleolar point. 

Age and sex appear to exercise some influence in the causation of 
sciatica. The disease occurs most frequently in the middle period 
of life, and is decidedly more common in the male than in the female. 
It is also noteworthy that the right leg is affected oftener than the 
left. In general, it may be said of sciatica that it is far less frequently 
due to constitutional causes than other forms of neuralgia. In most 
instances the neuralgia results either from injury or exposure to the 
combined influences of cold and dampness. Among the special excit- 
ing causes should be mentioned : Tumors within the pelvis, which 
irritate or compress the sacral plexus ; displacements of the uterus ; 
diseases of the rectum ; impacted fasces ; protracted labors ; forceps 
delivery ; popliteal aneurism ; morbid growths in the course of the 
sciatic nerve, and hemorrhoids. Double sciatica is an early symptom 
of locomotor ataxy. 

Kecent cases of sciatica readily yield to a judicious treatment, but 
chronic cases often prove very obstinate and relapses are common. 
Some degree of stiffness and feeling of tiredness in the limb often 
persist for weeks and months after recovery. 

Treatment. The possible removal of the exciting cause constitutes 
the primary indication of treatment. In those instances where such 
a procedure is impracticable, palliative measures form the only 
resource. The hypodermic injection of morphia is, perhaps, the only 
reliable means of allaying the pain during the severity of the 
paroxysm. Iodide of potassium and strychnia, in appropriate doses, 
are highly recommended, especially in cases of long standing. Turpen- 
tine is an old remedy in sciatica, which occasionally proves service- 
able. I witnessed its good effects in the case of a seaman at the City 
Hospital, who took the drug twice, in half-ounce doses, with perfect 
relief of the neuralgia that had troubled him for the past four months. 
Moist packing has been strongly advised by Kosenthal. I was 
favorably impressed with the results it yielded in cases where this 



52 MANUAL OF NERVOUS DISEASES. 

treatment was adopted; but it is generally agreed that blistering 
is, after all, the most promising mode of local treatment in the 
majority of cases. I am partial to the use of the cantharidal 
collodion. Galvanisation always deserves a trial, as it sometimes 
succeeds in effecting a cure when all other remedies fail. Anstie 
and Eulenberg assert that sciatica is more frequently cured by the 
constant current than any other species of neuralgia. 

Spermatic Neuralgia (" Irritable Testicle "). 

The external genital organs in both sexes are remarkably free 
from neuralgia; but the male is subject to very violent and intractable 
paroxysms of pain which start in one of the testicles and extend to 
the spermatic cord. This species of neuralgia is better known by 
the name of "irritable testicle." During an attack the testicle is 
retracted and the scrotum is exceedingly sensitive to the touch and 
appears slightly swollen. 

Such is the impotency of therapeutics in this form of neuralgia 
that desperate measures have been proposed for its cure. 

Hammond advises to keep up a pressure for fifteen minutes on the 
spermatic cord to crush the axis cylinders of the nerve. The appli- 
cation of ice to the scrotum gives only temporary relief. Perhaps 
galvanisation, which is now urgently recommended for this disorder, 
may have greater success. 

Angina Pectoris. 

Until the pathology of angina pectoris is better understood than 
it is at present, there is no impropriety in classifying this disorder 
among the group of visceral neuralgias ; at least its most prominent 
symptom consists of paroxysmal attacks of intense pain in the region 
of the heart. But associated with this pain are disturbances of 
circulation and respiration which do not enter into the definition of 
neuralgia. It has therefore been suggested that the set of symptoms 
comprised under the name of angina pectoris may rather be of the 
character of a neurosis affecting the sympathetic nerves that form 
the cardiac plexus. Physiological investigations appear to favor this 
view. 

Clinical History. Attacks of angina pectoris come on at irregular 
periods. Suddenly a pain of terrible intensity strikes the cardiac 



SPECIAL PATHOLOGY AND THERAPEUTICS. 53 

region, rapidly spreads over the left side of the chest and sometimes 
extends to the arm. Along with the pain there is a sensation of 
constriction and a peculiar dread of impending dissolution. The 
heart heats violently at first, but at the height of the paroxysm its 
action becomes irregular, intermittent, and then appears to cease 
altogether. Analogous changes in the condition of the pulse are 
observed. The respiration is hurried and panting, or suppressed; the 
latter symptom is owing to the effort of the patient to stay the pain 
by holding his breath. To complete this picture of physical 
suffering and mental anguish, the skin becomes pallid and cold, the 
face appears sunken, and a clammy perspiration breaks out on the 
surface at the close of the attack. A single paroxysm lasts but a 
short time, but there may be several attacks in quick succession. 

Etiology. There is a form of angina which accompanies hyper- 
trophy and fatty degeneration of the heart, valvular disease and 
calcification of the coronary artery. In other instances no lesion is 
discovered to account for the symptoms during life. The excessive 
use of tobacco is blamed for causing an irritability of the heart 
that is eventually destined to develop the affection. Mental shocks, 
gastric and intestinal disturbances are mentioned as exciting causes. 
Advanced age has a predisposing influence. Men are more liable to 
suffer from the attacks than women. 

Course and Termination. The course of the disease is always 
chronic. Attacks are of variable frequency. There may be a respite 
for years or a daily repetition of the paroxysms. In rare instances 
they cease spontaneously. Many patients live to an old age, but a 
person subject to angina is in imminent danger of death at every new 
onslaught. 

Diagnosis. Angina pectoris is easily recognized by the character 
of the intra- thoracic pain and its concomitant symptoms; but whether 
in individual cases the affection is due to structural disease of the 
heart is not so readily determined as may be supposed. Calcification 
of the coronary arteries is simply impossible to recognize, and fatty 
atrophy of the heart does not give rise to symptoms upon which a 
reliable diagnosis can be based. Now, these organic affections of the 
heart are, above all others, most frequently associated with angina. 

Of hardly less importance is the differential diagnosis between 
pseudo-angina pectoris and the genuine affection. Walsh e correctly 
observes that the imitation is of far more frequent occurrence than 



54 MANUAL OF NERVOUS DISEASES. 

the true disease. The symptoms of pseudo-angina, as described by this 
author, are " more or less severe pain referred to the region of the heart, 
commonly constrictive palpitations occurring paroxysmally without 
obvious cause, or under exertion, or through over-eating, indigestion, 
flatulent distention of the stomach and a variety of other functional 
disturbances. The breathing becomes panting and sighing. Giddi- 
ness and faintness are sometimes observed. The patient dreads efforts 
of all kinds." 

Treatment. A fit of angina bears such a close resemblance to the 
phenomena of shock that sedatives and stimulants appear to be 
urgently called for. In fact, the safest treatment during an attack 
consists of the administration of laudanum and brandy in quantities 
proportionate to the severity of the symptoms. The good effect of 
these remedies may be sustained by repeated doses of aromatic spirits 
of ammonia and the application of sinapisms to the chest and 
between the shoulders. It is very risky to administer chloroform or 
even ether. The cautious inhalation of nitrite of amyl is preferable. 

As a precautionary measure, the patient must avoid all exciting 
causes that may induce a recurrence of the paroxysm. His own 
experience will probably teach him to guard against the injurious 
influence of a hasty, ill-digested meal, irregularities of the bowels and 
undue exertion. Equanimity of mind and evenness of temper prove 
no less serviceable as preventives. 

Very little confidence can be placed in the efficacy of internal 
medication for the cure of the angina. Iron holds out the best 
chance in cases associated with anaemia. Duchenne achieved some 
success from cutaneous faradisation of the cardiac region in a case 
which was not complicated with organic heart trouble. 

Headache. 

As headache is merely a symptom, it follows that its clinical 
importance must be rated in accordance with its prominence and 
association with other phenomena. Thus all febrile affections and 
many diseases of the brain and the meninges are attended by head- 
ache. Pain in the head occurs, however, under circumstances which 
render it an object of special treatment. The character of the pain 
varies from a mere feeling of heaviness in the head to paroxysms of 
great violence. 

In attempting to classify the different varieties of headache, it must 



SPECIAL PATHOLOGY AND THERAPEUTICS. 55 

be understood that only the more ordinary forms are intended to be 
discussed. Facial neuralgia and hemicrania have already been 
described. The headaches characteristic of cerebral hyperemia and 
anaemia will be referred to in their proper places. 

Nervous Headache. Exhaustion of the nervous system from any 
cause or combination of causes is a fruitful source of manifold 
disorders, not the least of which is an exceedingly harassing head- 
ache, which is commonly attended by a hypochondriacal state of 
mind. There may be no actual pain in the head, but there is a dis- 
tressing sensation as If the head were compressed by a vice or crushed 
in from the top. Insomnia usually attends this troublesome symp- 
tom. Patients declare they will "go mad" if they get no relief, 
and some actually exhibit signs of insanity. 

The treatment must be directed to the abandonment, on the part 
of the patient, of all debilitating influences that tend to undermine 
the general health. Measures should be adopted which invigorate 
the nervous system. Temporary relief of the headache is sometimes 
obtained from sweet spirits of nitre, Hoffman's anodyne, chloric ether 
and aromatic spirits of ammonia, either singly or variously combined. 
General faradisation is highly recommended by Beard and Rockwell. 

Rheumatic Headache. Exposure to draughts of cold and moist 
air, when the head and neck are not well protected, occasions a form 
of headache which is diffused over the scalp, and may extend to the 
back and shoulders. Movement of the head aggravates the pain. 

Wrapping the head in a woollen shawl and keeping quiet affords 
relief. A Dover's powder should be given at bed-time to induce 
sleep. Severe cases are often benefited by salicylate of soda. 

Syphilitic Headache. Constitutional syphilis gives rise to a violent 
form of headache marked by nocturnal exacerbations. When such a 
pain in syphilitic patients does not depend upon pericranial disease 
or necrosed bones and is attended by insomnia, it may be the fore- 
runner of serious implication of the brain and meninges. Very large 
doses of the potass, iod. should be promptly administered in cases of 
this kind. 

Dyspeptic Headache. The headache resulting from gastric and 
intestinal disturbances is probably of a reflex character. Popular 
pathology ascribes nearly every form of headache to " biliousness or 
dyspepsia." That pain in the head is frequently a symptom of 



56 MANUAL OF NERVOUS DISEASES. 

indigestion and torpidity of the bowels cannot be gainsaid; but it 
is far from true that the majority of headaches own such an 
etiology. 

Should a brisk action of the bowels be indicated, there is nothing 
more reliable than the compound infusion of senna. A warm aloe tic 
pill, when hemorrhoids are not in the way, is a good derivative. A 
foul tongue is easily cleansed by bicarbonate of soda. 

Habitual Headache. The so-called habitual headache is the most 
wide-spread and intractable of all species of headache. Its parox- 
ysmal occurrence has been quaintly termed a " nerve storm." Prob- 
ably some congenital or hereditary tendency predisposes to its 
occurrence. There are people who are never without a headache. 

Absolute rest and quiet when an attack of more than usual inten- 
sity comes on give greater relief than anything else. Quinia aggra- 
vates the pain, and the continual use of morphia is objectionable. 
The monobromate of camphor in pills, from three to five grains, is 
occasionally of benefit. Among the empirical remedies may be 
enumerated caffein, thein, guarana, arsenic, the bromides, turpentine, 
and strychnia. 



CHAPTEE V. 

PERIPHERAL PARALYSIS. 

Traumatic Paralysis. Injuries to nerves from excision, laceration, 
contusion, etc., give rise to complete forms of peripheral paralysis. 
Lighter forms result from mechanical causes that compress a nerve, 
as sitting upon the edge of a hard substance for a considerable time, 
or lying on an arm crossed behind the back during sleep. 

Rheumatic Paralysis. This constitutes the most common form of 
peripheral paralysis. It is ascribed to "cold" or atmospheric influ- 
ences. Nothing definite is known respecting its pathology, though 
the paralyzed nerve must evidently have undergone some morbid 
alteration. 

Toxic Paralysis. A large number of poisonous substances cause 
paralysis when introduced into the general system. It suffices to 
mention lead, arsenic and mercury. Lead palsy usually makes its 
appearance subsequent to attacks of colic. In cases where the paralysis 
appears to be the first symptom, the other signs indicative of the 
presence of the poison may have been noted for some time, viz. : the 
blue line of the gums, the obstinate constipation of the bowels and the 
dry skin. The paralysis is often preceded by vague neuralgic pains 
in different parts of the body, more or less attended by numbness, 
formication, tremor and twitching of the muscles. In the majority 
of cases the extensors of the forearm become paralyzed, presenting the 
appearance popularly known as "wrist drop." All the muscles sup- 
plied by the musculo-spiral nerve may become successively paralyzed ; 
but it is singular that the supinator longus generally remains intaGt. 
The deltoid, and more rarely the serratus magnus, is occasionally 
involved, either singly or in combination with the extensors of the 
forearm. Atrophy of the paralyzed muscles rapidly ensues. Electric 
exploration gives characteristic results. In many cases there is an 
entire loss of electro-muscular contractility ; but generally the electric 
excitability corresponds in degree to the amount of nutritive changes 
which the affected muscles have undergone. 



58 MANUAL OF NERVOUS DISEASES. 

In the treatment of lead palsy, as in all cases of peripheral paralysis, 
the application of electricity holds out the best promise of a cure. 
Iodide of potassium is recommended for the purpose of eliminating 
the poison from the system. This is perhaps better accomplished by 
frequent hot baths, which stimulate the cutaneous surface and increase 
its secretions. The patient must be warned against future exposure 
to the deleterious influence of the metallic poison. 

Paralysis following Infectious Diseases. Paralysis is occasionally 
observed during the convalescence or after the complete subsidence 
of acute infectious diseases. It may thus occur as a sequela of 
diphtheria, typhoid fever, scarlatina, measles and variola. 

Diphtheric Paralysis is apt to develop from the third to the fourth 
week after the termination of the primary disease. The muscles of 
the soft palate are the first to suffer. This is indicated by the nasal 
character of the voice and difficulty of deglutition. When the muscles 
of the eye become affected, they cannot properly perform the function 
of associated movements. Strabismus is of rare occurrence. Paralysis 
of the extremities takes on the form of paraplegia. Diphtheric 
paralysis yields a favorable prognosis. Eecovery may be hastened by 
quinia and cod liver oil. 

Paralysis is the most frequent symptom of syphilitic lesions of the 
nervous system. As this subject will be considered more in detail in 
its proper place, it is at present only necessary to mention that certain 
cranial nerves are particularly prone to become paralyzed. Thus 
paralysis of the levator palpebrarum superioris (ptosis) is considered 
almost pathognomonic of cerebral syphilis. 

Ischcemic Paralysis. By this term is now understood a form of 
paralysis which depends upon an obstructed supply of arterial blood 
to the nervous apparatus. The hemiplegia resulting from throm- 
bosis and embolism of the cerebral arteries is a good example of 
ischaemic paralysis. But cases have been observed in which oblitera- 
tion of an arterial trunk, or the existence of an aneurism in various 
parts of the body, gave rise to peripheral paralysis. Charcot relates 
the following instructive case : A patient was affected with paralysis 
of the right leg whenever he attempted to walk, but the paralysis 
would disappear after he had rested for a few minutes. The autopsy 
revealed an aneurism of the right iliac artery ; the inferior third of 
the vessel had been converted into a ligamentous cord, and both 
divisions of the main trunk were, in comparison to those of the other 
side, considerably narrowed in their calibre. 



PERIPHERAL PARALYSIS. 59 

Acute Neuritis. The paralysis following acute neuritis is due to 
an inflammatory process which invades the constituent parts of a 
nerve. The anatomical changes consist of swelling of the nerve, 
enlargement of its capillaries and the presence of hemorrhagic spots 
in its tissue. The medullary matter disappears and the axis cylinder 
becomes granular and atrophies. Considerable febrile excitement 
marks the onset. Intense pain is felt along the course of the nerve 
and its distribution. The nerve is swollen and extremely sensitive 
to the touch. Anaesthesia and loss of reflex excitability of the parts 
may take the place of hyperalgesia. Paralysis of the muscles sup- 
plied by the affected nerve rapidly follows. An acute progressive 
neuritis has lately been described which is said to involve a large 
number of nerves in different parts of the body. 

Chronic Neuritis has the same etiology as the acute variety, and 
sometimes develops from the latter. The connective tissue of the 
neurilemma is greatly increased and compresses the nerve fibres ; or the 
latter may be the principal seat of the pathological changes. Finally 
the axis cylinder becomes thickened and shrivels, and the medullary 
substance disappears. The symptoms include sensory and motor 
disturbances of variable intensity. At first the patient may only 
experience a feeling of numbness or a furry sensation in the course 
and distribution of the affected nerve ; but very soon the parts become 
exceedingly sensitive and sometimes paroxysms of violent shooting 
pains occur. The pain, unlike that of neuralgia, progresses in a 
centrifugal direction ; no puncta dolorosa are found, but the nerve is 
tender on pressure and appears to be swollen. There is either 
complete anaesthesia of the parts, or only a creeping and tingling 
sensation ; and, in severe cases, twitching and spasms of the muscles. 
Paralysis, attended by more or less atrophy of the muscles supplied 
by the affected nerve, finally ensues. The modifications of electric 
reaction and the trophic changes are the same as in injuries to nerves. 

The treatment of acute neuritis calls for the application of leeches 
along the course of the nerve, followed by poultices. Immobility of 
the limb must be secured by splints. The paroxysms of pain can only 
be effectually relieved by injections of morphia. 

The therapeutics of chronic neuritis is directed against the 
paralysis and the muscular atrophy. Iodide of potassium is the 
most favored of internal remedies, though it yields in efficacy to 
electricity. The galvanic current is preferable to the faradic, but 
the latter may sometimes be advantageously employed. 



60 manual of nervous diseases. 

Special Forms of Peripheral Paralysis. 

Paralysis of the Ocular Muscles. The principal causes of paralysis 
affecting the different nerves distributed to the ocular muscles are 
atmospheric influences, intracranial syphilis, tumors, injuries of the 
orbit, lesions of the pons varolii and peduncles of the brain. Each 
one of the muscles may be involved either separately or in conjunction 
with others. The muscles implicated in these various forms of ocular 
paralysis can be accurately determined. This subject forms an inter- 
esting chapter in the special department of ophthalmology. It may be 
stated in general terms that every defective innervation of the exter- 
nal muscles of the eye necessarily interferes with their associated 
movements and the accommodation of the visual axis. These abnormal 
conditions are recognized by the development of strabismus and 
diplopia. 

Vertigo is a constant symptom resulting from the unaccustomed 
visual displacement of objects and the confusion caused by the 
double images. Closing the eyes stops the vertigo. 

The diagnosis, irrespective of the particular nerve or nerves which 
may be involved, depends upon the site of the lesion, whether it be 
peripheral or intracranial. Inquiries into the etiology may afford 
much information. Complications with affections of neighboring 
cranial nerves indicate a basilar lesion, usually syphilitic. A com- 
bination of paralysis of the face and the extremities points to 
disease of the pons or cerebral peduncles. 

Treatment. There is much of sameness in the treatment of peri- 
pheral paralysis wherever located. The rheumatic form of ocular 
paralysis suggests the administration of iodide of potassium, and, of 
course, the specific treatment promises the best results when syphilis 
is suspected. Electricity will be found useful in all cases amenable 
to treatment. Its application, however, requires some caution. Both 
the faradic and galvanic current must be of moderate strength. The 
electrodes should be applied over the closed eyelids and near to the 
insertion of the affected muscles. 

Facial Paralysis. The face in complete unilateral paralysis pre- 
sents a striking and characteristic appearance. This depends upon 
the immobility of the muscles of expression which are supplied by 
the seventh nerve. On the paralyzed side of the forehead no wrinkles 
are visible; the folds of the glabella do not show, owing to inactivity 
of the corrugator supercilii; the lower eyelid droops and the eye 



PERIPHERAL PARALYSIS. 61 

cannot be voluntarily closed, because of the loss of motion of the 
orbicularis palpebrarum. Paralysis of the dilators of the nose 
causes flattening of the alae nasi. The labio-nasal fold is effaced 
on account of inaction of the levators. The want of antagonism of 
the muscles that converge at the corner of the mouth allows the 
mouth to be drawn towards the opposite side, and hence there occurs 
deviation of the lips and difficulty of completely closing the mouth. 
This permits the escape of saliva. For a similar reason the acts of 
whistling, blowing, spitting and sucking, and the articulation of the 
labial sounds, are rendered difficult and sometimes impossible. This 
motionless condition of the muscles of one side of the face becomes 
particularly apparent when the patient speaks, laughs or cries. 
Although the masticatory muscles are not affected, there is, never- 
theless, much hindrance offered to the chewing of food, which is due 
to the flabby condition of the muscles of one side of the cheek. 
Morsels of food lodge between the gums and the cheek, which the 
patient is obliged to remove with his fingers. Another troublesome 
symptom is the constant weeping from the open eye. Double facial 
paralysis is a very rare affection (Diplegia Facialis). 

Rheumatic Facial Paralysis. "Bell's Paralysis." That facial 
paralysis may directly result from a cause which it is customary to 
designate as rheumatic, is proved by instances where one side of the 
face suddenly becomes paralyzed from its exposure to a raw wind, 
whilst sitting near an open window in a railroad car, or standing near 
a partly open street door. In other cases where no such palpable 
causes can be assigned, it must be assumed that some obscure atmos- 
pheric influences acted upon a person predisposed to this species of 
paralysis. What morbid changes take place in the affected nerve 
remain yet to be determined. Those cases in which the nerve 
becomes involved within the Fallopian canal are apt to be associated 
with the disturbances of hearing and taste, and occasionally with 
lateral deviations of the uvula and obliquity of the velum palati. 

The onset of rheumatic facial paralysis is abrupt. Nearly all the 
external muscles of one side of the face are implicated. In the course 
of the first few months more or less improvement may be expected; 
but complete restoration of motility is exceptional. Some disfigure- 
ment of the features, when the person gives expression to any 
emotional excitement, can be noticed even in cases which seem to 
have perfectly recovered. This distortion of the features in bad 



62 MANUAL OF NERVOUS DISEASES. 

cases becomes exaggerated by occasional spasmodic movements and 
permanent contracture of the facial muscles. 

The abnormal electric reactions characteristic of rheumatic facial 
paralysis are of diagnostic and therapeutic importance. There is no 
uniformity in individual cases as regards the stage when electric 
exploration discovers diminution or total loss of the farado-muscular 
contractility. Absence of the faradic reaction early in the disease is 
an unfavorable sign, notwithstanding the remarkable fact that the 
galvano-muscular contractility may at the same time be increased, 
so that comparatively few elements will suffice to produce vigorous 
contractions of the paralyzed muscles (RD). But many modifications 
of electric reaction are noticeable during the course of the disease. 
In the event of progressive degenerative changes taking place in the 
nerve and muscles, there will finally be no response to either kind of 
electricity. 

Facial paralysis of short duration in infants is sometimes witnessed 
from the effects of forceps delivery. The infant is unable to take the 
breast, as it cannot perform the act of sucking. 

Syphilitic periostitis and exostosis affecting the base of the cranium 
often give rise to all the symptoms characteristic of peripheral facial 
paralysis. 

Lesions of the pons varolii produce a similar effect. The facial 
paralysis is then usually complicated with hemiplegia. 

Diagnosis. The diagnosis of facial paralysis mainly turns upon the 
question of the localization of the lesion. The etiology of the indi- 
vidual case, but more especially the extent of the paralysis and its 
complications, afford the most reliable information. It is obvious 
that in paralysis of all the muscles of one side of the face the trunk 
of the facial must have been caught by a lesion not higher than the 
pons. If only the muscles of the lower part of the face are paralyzed, 
then the lesion probably exists in the central ganglia. As a rule, 
facial paralysis of cerebral origin is complicated with hemiplegia, and 
the electric reaction of the nerve and muscles is found to be normal. 
The associated symptoms of deviation of the uvula, and unilateral dis- 
turbance of taste and hearing, speak for the situation of the lesion 
within the Fallopian canal. Complications with paralysis of other 
cranial nerves point to intracranial disease. The peculiarities of elec- 
trical reaction, indicating the nutritive changes of the affected nerve 
and muscles characteristic of peripheral paralysis, are of great diag- 
nostic value. 



PERIPHERAL PARALYSIS. 63 

Treatment. As electricity is undoubtedly the most sovereign 
remedy in all forms of peripheral paralysis, and renders every other 
therapeutical measure superfluous — at least in the large majority of 
cases — it will only be necessary to indicate its mode of application. 
The interrupted current sometimes answers the purpose in ordinary 
cases. A current of moderate strength should be successively applied 
to the several muscles for a short time. When recent cases do not 
yield within a reasonable time, then the combined or alternate use of. 
the faradic and galvanic currents should be tried. Cases in which the 
farado-muscular contractility is abolished are but seldom amenable to 
any plan of treatment.' Galvanisation is preferable in old and obstinate 
cases, and for the relief of cramps and secondary contractures. The 
kathode is applied to the paralyzed muscles or to the nerve, and the 
anode to an indifferent part — the top of the sternum or the nape of 
the neck. 

The application of leeches and fly-plasters to the region of the 
stylo-mastoid foramen may, perhaps, be of service in very recent 
cases ; but these local measures, and the customary administration of 
iodide of potassium and strychnia in old-standing cases, cannot replace 
electricity. Even in those instances where the causal treatment is 
indicated, as in affections of the parotid glands and otitis, electricity 
may be advantageously employed after the removal of the primary 
cause. Syphilitic facial paralysis must be combated by the usual 
constitutional treatment. 

Laryngeal Paralysis. 

Motor disturbances, ranging from slight paresis to complete 
paralysis of the muscles engaged in respiration and phonation, are 
met with in the larnyx. A single muscle or a group of muscles inner- 
vated by a single nerve branch, or a group of muscles sup- 
plied by different branches, but associated in some physiological act, 
may be affected. Paresis of the tensors of the vocal cords, and almost 
constant symptom of acute catarrh of the larnyx, is principally due 
to muscular infiltration, and is usually symmetrical. Total para- 
lysis of a muscle or group of muscles is, in the great majority of cases, 
unilateral and of peripheral origin. Nervous disturbances in the 
throat, dependent upon disease of the brain or spinal cord, are 
extremely rare. Tumors of the trachea, oesophagus and mediastinum, 
or aneurisms of the great vessels of the heck, which press upon the 



64: MANUAL OF NERVOUS DISEASES. 

recurrent laryngeal nerve somewhere in its course to the larynx, are 
the most common causes of the paralyses of this region. It will be 
remembered that the inferior laryngeal supplies all the muscles of the 
larynx, except the crico-thyroid and part of the transversus. The 
various forms of paralysis, whether affecting the adductors or abduc- 
tors of the cords, or the constrictors of the larynx, give typical 
pictures in the laryngoscope and characteristic quality to the voice, 
which render them easy of recognition. 

A loss of the power of co-ordination during phonation is some- 
times witnessed in hysterical women, and may easily be mistaken for 
palsy of the cords ; repeated laryngoscopic examinations serve to 
distinguish this affection from true paralysis. 

Spasms of the laryngeal muscles, besides being exhibited in the 
laryngismus strideolus of infants, occurs in chorea, epilepsy, hydro- 
phobia and strychnia poisoning. Atrophy, especially of the muscles 
proper of the cords, sometimes occurs in tuberculous patients, and 
may further be brought about as an effect of long-standing paralysis. 

Immobility of the vocal cords from anchylosis of the arytenoid 
cartilages, after the throat ulcerations of syphilis and typhus, is, 
happily, not often met with. 

Treatment. Besides the casual treatment indicated in laryngeal 
paralysis, much assistance is obtained from the employment of elec- 
tricity. Brilliant results are sometimes witnessed from the inter- 
rupted current in hysterical aphonia. The sponges should be applied 
to the side of the neck which corresponds to the location of the vocal 
cord. By means of McKenzie's electrode the affected cord can be 
directly stimulated. 

Paralysis of the Sterno-Cleido-Mastoideus and Trapezius 

Muscles. 

Both these muscles receive motor branches from the spinal acces- 
sory and the cervical plexus. Prolonged mechanical pressure of the 
parts has been known to produce isolated paralysis of these muscles ; 
but in the greater number of cases in which no traumatic causation 
can be assigned, the paralysis must be ascribed to a rheumatic 
influence. In one-sided paralysis of the sterno-cleido-mastoid, the 
head is inclined to the healthy side and the chin is directed towards 
the affected side. The deformity can be easily corrected by passive 
movements of the head. Atrophy, and finally contracture of the 



PERIPHERAL PARALYSIS. 65 

paralyzed muscles, ensue in long-standing cases. The differential 
diagnosis between paralysis and spasmodic contracture of this muscle 
(Torticollis) consists in the circumstance that in the former case 
the inclination of the head can be temporarily rectified by passive 
movement, which cannot be done when the muscle is spasmodically 
contracted. 

The clavicular attachment of the trapezius is usually affected in 
partial paralysis of this muscle. This is shown by defective eleva- 
tion of the shoulder. 

Paralysis of the Serratus Magnus. 

Isolated paralysis of this muscle causes sinking of the outer border 
of the scapula and elevation of its inner border. Besides this charac- 
teristic position of the scapula, the patient is unable to raise the arm 
beyond the horizontal line. This movement carries the scapula back- 
ward toward the spinal column. The groove formed by the spinal 
processes is then filled up by the volume of the muscle. 

Paralysis of the Latissimus Dorsi has been observed to result from 
lifting heavy weights. The characteristic sign of paralysis of this 
muscle is the wing-shaped appearance of the scapula, which stands 
out from the thorax. 

Paralysis of the Upper Extremities. 

Paralysis of the deltoid is most frequently caused by injuries to the 
shoulder. The patient is unable to raise the arm to the head, and 
the shoulder appears sunken. Should the infra-spinatus muscle be 
paralyzed at the same time, then abduction of the arm becomes impos- 
sible, which prevents the acts of drawing, writing, etc. 

Peripheral paralysis in the distribution of the radial nerve is of 
frequent occurrence, owing to the liability of this nerve to suffer 
from injuries and exposure to rheumatic influences. This nerve is 
particularly prone to be affected by saturnine palsy. It may be said, 
in general, of paralysis of the radial nerve, from whatever cause, that 
nearly all of the extensor and abductor muscles of the arm and hand 
become involved. The wrist drops, the hand loses its grasp, and the 
fingers cannot be extended nor applied to any purpose. In lead para- 
lysis, however, the supinator longus remains singularly exempt. 
More or less anaesthesia or paresthesia is usually associated with the 
paralysis. Diminution of the electro-muscular contractility is noticed 



66 MANUAL OF NERVOUS DISEASES. 

before long, and, if improvement does not soon follow, it may be 
entirely lost. Finally contractures and atrophy of the affected muscles 
indicate degeneration of the nerve. 

Paralysis of the upper extremities from central lesions is not 
attended by anaesthesia nor loss of electro-muscular contractility. It 
is further distinguished by the history of the case and the concomi- 
tant symptoms. 

Treatment. In regard to the treatment of paralysis of isolated 
muscles of a rheumatic nature, and that resulting from slight trau- 
matic causes, the greatest dependence must be placed on electro- 
therapy, though a systematic course of friction and massage should 
not be neglected. 

Paralysis of the Lower Extremities. 

The most common example of isolated paralysis of the muscles of 
the lower extremities is observed in the disease known as the spinal 
paralysis of children. Those of a peripheral nature occur from 
injuries in the distribution of the crural and sciatic nerves, especially 
during difficult labors and from compression of intra-pelvic tumors. 
Eheumatic influences and some obscure affection of the nerves 
following acute diseases also give rise to paralysis of the lower 
extremities. 

When the crural nerve alone is involved there is an arrest of the 
action of those muscles which raise the trunk from a sitting posture 
and straighten the knee; but paralysis of the lower extremities 
happens far more frequently from disease of the sciatic nerve. Any 
of its principal branches may be exclusively involved, and lead to 
manifold deformities of the limb. 

Treatment. Electro-therapy accomplishes excellent results in cases 
of recent origin, and even deserves a trial in those of a chronic order 
that have not yet advanced to complete loss of the electro-muscular 
contractility. 



CHAPTER VI. 
SPASMODIC AND ALLIED AFFECTIONS. 

Spasms of the Oculae Muscles. 

Hardly more than a brief allusion to this subject is necessary in 
this place, since it is more appropriately considered in works treating 
on diseases of the eye. 

Tonic Spasm of the levator palpebrae superioris rarely occurs in an 
isolated form. This affection causes fixation of the upper eyelid, so 
that the eye cannot be voluntarily closed (Lagophthalmos Spastica). 
Its occurrence depends either upon a peripheral or a central source of 
irritation. 

That form of strabismus which is frequently noticed in conjunc- 
tion with symptoms denoting cerebral disease is due to a tonic spasm 
of the external muscles of the eyeball. It is also observed as a tran- 
sient symptom of a reflex character during dentition, and in the 
intestinal affections of children. 

The involuntary oscillatory movements of the eyeball called 
nystagmus result from clonic spasms of the ocular muscles. In 
the majority of instances it is a symptom of various affections of 
the eye ; but it may also depend upon intracranial lesions, or be merely 
a reflex phenomenon due to irritation of remote organs. 

The sphincter of the eye is subject to clonic and tonic spasms. In 
the former instance the iris contracts and dilates in rapid succession 
(Hippus). This is, in most cases, a symptom of retinal irritability. 

Contraction of the pupils due to tonic spasm of the iris indicates 
peripheral or central excitation of the oculo-motor nerve. It is 
important to distinguish this form of myosis from that due to 
paralysis of the oculo-spinal center. 

Treatment. The spasmodic affections of the ocular muscles, which 
have been mentioned, obviously require a causal treatment. 

Spasms Occurring in the Course of the Trigeminus. Trismus, or 
" lock jaw," is a bilateral tonic spasm of the masseter and temporal 



68 MANUAL OF NERVOUS DISEASES. 

muscles, which are both supplied by motor fibres of the trifacial 
nerve. This formidable symptom is invariably present in tetanus. It 
is not uncommonly witnessed in violent hysterical fits, and may even 
persist for a considerable length of time after the subsidence of the 
paroxysm, as I have observed in several instances. Kheumatic trismus, 
according to my experience, is unilateral. It is attended by pain, which 
the patient locates in the jaw, behind the ear and about the neck. This 
form of trismus is best treated by hypodermic injections of morphia 
and the application of dry heat. 

Spasms Occurring in the Course of the Facial Nerve. The muscles 
to which the facial nerve is distributed are subject to partial and 
general spasms. Both kinds of spasms are commonly of a reflex 
character. Any exciting cause that acts directly upon the trunk of 
the nerve, its central connection or its peripheral expansion, can give 
rise to convulsive movements of the facial muscles. 

Involuntary closure of the eye from tonic spasm of the orbicularis 
palpebrarum muscle (Blepharospasm) is nearly always associated 
with various affections of the eye, particularly with conjunctivitis and 
ulceration of the cornea. This connection shows the reflex nature of 
the contraction. Blepharospasm usually affects both eyes. Immod- 
erate winking, which in a milder form is habitual with some people, 
results from clonic spasms of the eyelids. As a reflex phenomenon 
it frequently complicates spasms of other facial muscles. 

Single muscles and groups of muscles of the face are subject to 
spasmodic movements under a variety of circumstances. The 
so-called " tricks " are probably of a congenital or hereditary char- 
acter. One of the earliest symptoms of general paresis is a quivering 
of the upper lip. This is also frequently noticed in elderly persons. 
Violent spasms of the facial muscles occur in intracranial tumors 
and in chronic syphilitic meningitis. 

General clonic spasms of the face (Tic convulsif ) cause contor- 
tions of the features. The grimaces which are thus involuntarily 
produced are distressing to witness. The forehead from violent action 
of the occipito-frontalis muscle is thrown into deep folds. There is 
compression of the eyelids, rimpling of the nose, twisting of the 
mouth, twitching of the chin, etc. In cases of a reflex character, 
usually complicated with neuralgia of the trigeminus, the spasms are 
readily excited by the acts of mastication, laughing, and even talking. 



spasmodic and allied affections. 69 

Spasms of the Steeno-Mastoideus and the Teapezius. 

Eheumatic influences affecting the superficial branches of the 
spinal accessory nerve often give rise to spasms and contractures of 
the muscles that rotate and bend the head. The ordinary "wry 
neck" is of this character. Nodding of the head is occasionally 
noticed in children who suffer from disease of the vertebrae. Tonic 
spasms of the stern o-cleido-mastoid produce forcible rotation of the 
head — the chin being directed to the healthy side and the head to the 
affected side. The belly of the muscle appears to be swollen. This 
deformity cannot be rectified by passive movements. At a later stage, 
the symmetrical muscle of the opposite side wastes, which increases 
the deformity. Tonic spasms and contracture of the trapezius cause 
a similar deformity ; but the head is retracted and inclined to the 
affected side. The upper portion of the muscle bulges considerably. 

Treatment. It is of paramount importance, in view of the reflex 
character of most of the forms of spasms that have been mentioned, 
to pay attention to the primary cause. Those cases which compli- 
cate neuralgia often yield to the hypodermic injection of morphia. 
Even as a palliative it is superior to any other remedial measure in 
instances that admit only of a symptomatic treatment. Galvanism is 
also worthy of a trial. 

Weitee's Ceamp. 

The nervous disorders which interfere with the co-ordination of 
movements necessary in avocations that require the delicate use of 
the hand and fingers — as in sewing, writing, drawing, and performing 
upon musical instruments — may be conveniently grouped under the 
above affection, which is the most common and best known of the 
" Artisan's Cramp." The disturbance of the muscular mechanism in 
writer's cramp is brought about partly by a spasmodic condition, and 
partly by a certain degree of paresis of the thumb, the index and 
middle fingers, which are all engaged in the act of writing. There may 
be either rigid extension of the index finger, which releases the hold 
on the pen, or the pen is tightly pressed between the thumb and the 
index finger, as both become affected by the tonic spasm. Sometimes the 
thumb or the middle finger becomes firmly flexed on the palm, which 
renders the grasp of the pen impossible. Should the person still be 
enabled to retain the pen in its proper position, he contrives to write by 
firmly pressing the forearm against the desk ; but the arm soon tires and 



70 MANUAL OF NERVOUS DISEASES. 

begins to tremble, pain is felt along its whole extent, and not seldom 
the limb is seized by clonic spasms. In some persons the affection 
commences with tremors and weakness of the arm and ringers, 
which not only renders the act of writing irksome, but often causes 
the pen to drop from the hand. It is remarkable that the gross 
motor power of the limb remains normal, and that any manner of 
work, except writing, which requires nicety in the use of the hand and 
fingers, can be performed without difficulty. So soon as the pen is 
laid down there is a cessation of the cramp. 

The Etiology of writer's cramp is quite obscure. The inordinate 
use of the pen appears to act as the exciting cause in individuals in 
whom there exists a neuropathic element. There can hardly be any- 
thing particularly hurtful in the use of the steel pen, which is now 
in common use, for writer's cramp was observed when only quills 
were used. 

Nothing positive is known concerning the pathology of this nervous 
affection. Morbid anatomy is silent regarding its distinctive 
anatomical changes. 

The Diagnosis of writer's cramp offers no difficulties. It is only 
carelessness that would confound it with senile trembling of the hand, 
with immobility of the fingers from chronic rheumatism, or with the 
ataxic condition of these parts in tabes dorsalis. 

The Prognosis of writer's cramp is not favorable — a permanent 
cure being the rare exception. The disorder progresses from bad to 
worse if treatment does not effect some improvement. 

Treatment Writing must be strictly prohibited, whatever mode 
of treatment be adopted. The many contrivances that have been 
invented for steadying the fingers in holding the pen exercise no 
curative effect. Learning to write with the sound hand is of little 
avail, for it is liable to become affected like the other. Friction of 
the parts with stimulant or sedative liniments is useless ; massage, 
however, is not seldom of temporary benefit. Strychnia has proved 
itself harmful even in cases of a marked paretic nature. Duchenne 
does not speak encouragingly of the interrupted current in this 
affection, but galvanisation is indubitably of benefit. Temporary 
amendment of the spasm and tremor not only follows the use of this 
form of electricity, but even permanent cures have been effected by 
it. The mode of application must vary with the localization of the 
cramp and tremor. It is best to apply the anode to the affected 
muscles and nerve trunk, and the kathode to the spine. From 15 to 



SPASMODIC AND ALLIED AFFECTIONS. 71 

30 elements may be used. Each sitting should last about 10 minutes, 
and be repeated every other day. Tenotomy has been successfully 
practiced in a few cases. . 

Paealysis Agitans ("Shaking Palsy"). 

Tremor constitutes the essential symptom of this affection. A 
muscular weakness, which seldom advances to complete paralysis, 
soon becomes superadded, and frequently the violent action of some 
of the antagonistic muscles causes sudden jerking of the head and 
limbs. The abnormal movements, as a rule, begin in the hand and 
arm of one side, and then gradually become general. In some cases 
they are confined to one side of the body, or only to one extremity. 
At first the patient is able to control the shaking to some extent by 
a strong voluntary effort, or by leaning against a support. Mental 
commotions or unusual physical exertions aggravate the shaking. 
The tremor interferes with speech and the act of deglutition, and 
also causes disturbance of many other motor functions, but ceases 
during sleep. The paralysis which develops subsequent to the 
appearance of the tremors is most apparent in the extensors of the 
forearm. This, in connection with tonic contraction of the antago- 
nistic muscles, occasions deformity of .the fingers. At a later period, 
when the paralysis increases, there is unsteadiness of gait, the head 
leans forward and the body is often seized with propulsive movements. 
Complications of sensory disturbances, such as tingling, formication 
and incomplete anaesthesia, are less frequently observed than the 
cephalic symptoms, — headache, vertigo, insomnia, etc. The approach 
of the fatal termination is indicated by the continuance of the tremor 
during sleep, and general disturbance of the vital functions. Many 
patients are carried off by intercurrent diseases. 

Etiology. Paralysis agitans is an affection of advanced life. From 
this it has been inferred that senile decay acts as a predisposing 
cause. The disease is mostly observed to occur in persons who have 
experienced a great deal of hardship in life. 

Our knowledge of the pathology of this disease is as meagre as 
that of its causation. The few post-mortem examinations that have 
been reported gave negative results as regards any uniform lesion 
of the nervous system, though various anatomical changes were 
noticed in different parts of the brain and spinal cord. 



72 MANUAL OF NERVOUS DISEASES. 

The Differential Diagnosis must distinguish paralysis agitans from 
the following affections : Senile, mercurial and saturnine tremor ; the 
tremor of alcoholism and of multiple sclerosis. The movements of 
senile tremor are less violent than those of shaking palsy, and they 
are not attended by semi-paresis and deformity of the extremities. 
Mercurial and saturnine tremor can be easily recognized by the 
symptoms which are peculiar to the morbid action of each of these 
metals upon the human system. Alcoholic tremor is attended by a 
peculiar form of delirium. The tremor of sclerosis is evoked only 
when the patient attempts to carry out some voluntary movement. 
A tremor greatly resembling that of paralysis agitans has been noticed 
in young persons after a mental shock, such as a sudden fright or 
terror. 

The Prognosis of paralysis agitans is bad ; improvement, even in 
recent cases, being rarely observed. 

Treatment. It would be unprofitable to enumerate all the remedies 
that have been tried in this disease without any satisfactory results. 
The prolonged use of the subcarbonate of iron appeared to have been 
successful in a case reported by Elliotson. Charcot's case derived 
some benefit from hyoscyamine. Eeynolds observed good results from 
the wearing of a " Pulvermacher's chain.'' Galvanism seems to 
palliate the tremor. Hypodermic injection of morphia is followed 
by temporary mitigation of this symptom. I have seen no improve- 
ment from large doses of chloral hydrate and the bromides. 



CHAPTER VII. 

DISEASES OF THE MEMBRANES OF THE 
SPINAL CORD. 

Hyperemia of the Meninges. 

A congested condition of the spinal membranes, due to the posi- 
tion of the corpse, which favors the gravitation of the blood towards 
the vertebral column, is a very common post-mortem appearance. 
Fullness of the meningeal bloodvessels in persons who have died 
from convulsions or asphyxia is equally devoid of pathological sig- 
nificance. But spinal symptoms in stasis of the venous circulation, 
as in portal obstruction, suppression of the menses, etc., suggest the 
existence of hyperemia of the meninges. Experience has taught that 
these symptoms are best treated by antiphlogistic measures. The 
pain in the back, the morbid sensibility and the feeling of numbness 
and formication in the lower extremities, are found to yield readily to 
wet cups and cold douches to the sacrum, and the administration of 
saline cathartics. 

Hemorrhage of the Meninges. 

Injuries to the spinal column are liable to give rise to extravasation 
of blood in the venous plexuses, between the vertebrae and the dura 
mater. The symptoms of " spinal apoplexy " develop suddenly and 
with great violence. The pain in the back is intense ; the patient 
falls over as if shot, his lower extremities become powerless, and the 
nervous prostration is extreme. After a variable time, not exceeding, 
however, twenty-four hours, the effects of the shock pass off and give 
place to a group of symptoms characteristic of spinal meningitis. 

Spinal Meningitis. 

Suppurative inflammation of the pia mater of the cord is frequently 
associated with a similar affection of the cerebral membranes. The 
simple or sporadic form of spinal meningitis is a rare disease. Its 



74: MANUAL OF NERVOUS DISEASES. 

etiology is obscure; but probably exposure to cold and dampness, 
acting directly upon the spine, constitutes the exciting cause. 

Anatomical Changes. The tissue of the pia mater is filled with an 
inflammatory infiltration that extends to the meshes of the arachnoid. 
The membrane is injected, thickened and dense, particularly on the 
posterior aspect of the cord. Fibrinous deposits are gathered on the 
inner surface of the dura mater, and a serous or purulent exudation 
(the latter of a yellowish -green color) is sometimes spread over the 
whole length of the cord. In some cases there is an entire absence of 
the exudation, so that the pia mater only shows deep vascularization. 

Clinical History. In many cases the symptoms of spinal menin- 
gitis are mixed up with " head symptoms," resulting from the simul- 
taneous implication of the cerebral meninges. Under these circum- 
stances the spinal affection is only of secondary importance. An 
analogous combination of symptoms is presented in myelo-menin- 
gitis; but here, again, the meningeal symptoms play but a subordinate 
part. Simple acute inflammation of the membranes of the cord 
exhibits marked characters. The most prominent is pain along the 
spine and in the extremities. This is attended by stiffness of the 
muscles of the trunk and limbs. The least movement of the body 
brings on fits of pain and muscular rigidity, and, for this reason, the 
patient lies perfectly quiet, and represses even the acts of coughing 
and sneezing. This voluntary immobility presents the appearance of 
loss of muscular power, but paralysis is not a symptom proper to spinal 
meningitis. The muscular stiffness bears great resemblance to tetanic 
contractions. In explanation of this symptom it has been suggested 
that the rigidity is probably due to the instinctive effort of the patient 
to prevent the pain by keeping his body and extremities at rest; and, 
in fact, it is noticed that he is free from the pain and rigidity so long 
as he avoids movements. Some degree of hyper aesthesia is always 
present, and also an increase of reflex excitability. Loss of power 
over the bladder, preceded by frequent desire to pass urine, is also 
a very marked symptom. The bowels are confined, and fever, if 
present at all, is moderate. 

Diagnosis. The clinical peculiarities of acute spinal meningitis are 
not easily mistaken for spinal hyperemia or tetanus. The chief 
features of the latter disease (the trismus and the spasmodic paroxysms, 
which recur whether the patient be moving or at rest) offer sufficient 
points of differential diagnosis. 



THE MEMBRANES OF THE SPINAL CORD. 75 

Prognosis. When "head symptoms" make their appearance, or 
when the meningeal inflammation has resulted from a traumatic 
cause, prognosis is unfavorable. Cases in young persons, due to 
rheumatic influences, not infrequently recover. 

Treatment. The local abstraction of blood, the application of the 
ice-bag to the spine, and iodide of potassium internally, constitute the 
approved remedies in acute spinal meningitis. The pain must be 
subdued by injections of morphia. Such an active treatment is, 
however, out of place if the disease becomes chronic. In the latter 
event, attention is^ rather directed to the associated symptoms of 
myelitis. 

Epidemic Cerebro-Spinal Meningitis. 

A virulent type of this disease proved very fatal in the camps and 
barracks of the Northern and Southern armies during the late civil 
war. Epidemics of a limited extent have since then appeared in 
different parts of the country. In 1871 an epidemic of brief duration 
visited this city, which mostly attacked children. The name of 
"spotted fever" is given to this disease in many localities, on account 
of various skin eruptions that make their appearance during its 
course. 

Anatomical Changes. The pathological changes found after death 
show decided evidences of meningeal inflammation within the cranium 
and spinal canal. A more or less abundant exudation of lymph and 
pus collects beneath the arachnoid. When limited in quantity it is 
most copious at the base of the brain. Different parts of the cord or 
its whole length may be covered by the purulent deposit. The 
ventricles are sometimes filled with a turbid fluid. Occasionally the 
substance of the brain and of the spinal cord exhibits minute spots 
of softening. It is remarkable that the most virulent type of the 
disease does not always show decided evidences of an inflammatory 
process. 

Clinical History. The premonitory symptoms are of an ill-defined 
character. For a few days preceding the invasion, patients complain 
of headache, lassitude, nausea, and perhaps repeated shivering. A 
decided chill is not common. In an epidemic reported by Dr. 
Githens, which he witnessed in Philadelphia, in 1867, the prodromic 
stage averaged eight days. 



76 MANUAL OF NERVOUS DISEASES. 

The full development of the disease is characterized by the acces- 
sion of fever, intense headache, pain in the spine and rigidity of the 
muscles of the neck. During the course of the disease a number of 
other symptoms are observed which mainly depend upon the menin- 
geal inflammation. The febrile movements present nothing peculiar, 
At the commencement the fever is usually of a high grade and shows 
irregular remissions and exacerbations. 

Cephalalgia is one of the most constant symptoms. The pain is 
sometimes of such extreme violence that patients become almost 
frantic from its persistence. 

The rhachialgia is most intense in the sacral region. The least 
movement of the body, as in rising and turning in bed, starts and 
aggravates the pain. Darting and lancinating pains also affect the 
lower extremities. Very young children evince their fear of the pain 
on being disturbed, by screaming whenever they are about to be lifted 
from the bed, or are made to change their position in feeding and in 
dressing. A very conspicuous symptom of the disease is rigidity of 
the muscles of the neck, frequently combined with retraction of the 
head. Even in those instances where this symptom seems to be 
absent, it will be found that the patient is unable to approach the 
chest with his chin. The exalted sensibility of the skin and muscles 
is especially well marked in the lower extremities. Sometimes the 
heightened reflex excitability is of such an acute character that the 
slightest touch of the body, or even footsteps in the sick-room, cause 
the patient to start up and to shudder. Probably the rigidity of the 
spinal column, amounting sometimes to opisthotonos, results from 
reflex action superinduced by hyperesthesia. Trismus is but rarely 
observed. 

Vomiting is an exceedingly troublesome symptom, but usually it 
stops soon after the onset, though it is liable to return during the 
course of the disease. 

Among the less constant symptoms may be mentioned delirium, 
somnolence and stupor. The initial stage in children is frequently 
attended by general convulsions. Cramps of the muscles of the back, 
thighs and legs are not uncommon. 

Disturbances of the special senses constitute the most serious com- 
plications of the disease. During its height there is considerable 
deafness, and this may unfortunately lead to total loss of hearing. 
In children of tender age it usually leads to deaf-mutism. The 
eyes become affected in various ways. Ulceration of the cornea 



THE MEMBRANES OF THE SPINAL CORD. 77 

belongs to the earlier stage. Inequality of the pupils comes on later. 
Great dilatation of both pupils is a grave symptom. Amaurosis is 
principally due to a descending neuritis which eventually terminates 
in atrophy of the optic disk. 

The urinary functions are seldom disturbed. Children are occa- 
sionally troubled with repeated and painful micturition. 

Cutaneous eruptions constitute a marked feature in many of the 
epidemics. Clusters of herpetic vesicles appear on the lips, nose and 
cheeks. Eoseolar spots and copious crops of urticaria are sometimes 
noticeable at an. early date. Petechise are less common. 

Course and Duration. The preceding analysis of the symptoms, 
in place of a consecutive description of the phenomena that mark the 
clinical history of cerebro-spinal meningitis, is rendered necessary by 
reason of the irregular and variable course of this disease. During 
the prevalence of an epidemic, cases come under notice which differ in 
many respects from the ordinary type. What has been designated as 
the " explosive " or " fulminant " variety is a most terrible affection. 
Persons appear to be stricken down at once by the intensity of the 
morbid cause. The sudden collapse of such patients, from which they 
seldom recover, is probably due to paralysis of important nerve 
centers. On the other hand, very mild or so-called abortive cases are 
occasionally observed which would hardly be recognized, were it 
not for their occurrence at the time of an epidemic. 

The sporadic form of cerebro-spinal meningitis is of a very rare 
occurrence. It differs in no essential particulars from the epidemic 
variety. 

Unfavorable cases, as a rule, run a rapid course. The greater pro- 
portion do not survive the fifth day. In malignant cases, death may 
ensue in less than thirty-six hours. The average duration is about 
sixteen days. A fatal termination in protracted cases is to be feared 
from the effects of extreme emaciation. The rate of mortality ranges 
from 30 to 75 per cent. 

Etiology. Epidemic cerebro-spinal meningitis must be classed with 
the acute infectious diseases. This is evident from its simultaneous 
occurrence in a number of individuals who inhabit the same town or 
district. The characteristic symptoms of the disease, however, are 
mainly due to the meningeal inflammation. The conditions which 
favor the development of an epidemic are overcrowding in camps, 
jails, barracks, etc. More males are attacked than females. 



78 MANUAL OF NERVOUS DISEASES. 

Diagnosis. The prominence of cerebral and spinal symptoms, when 
observed in connection with a high grade of fever which attacks a 
number of persons at the same time, renders diagnosis comparatively 
easy. Exceptional severity of the " head symptoms " in typhoid fever, 
and in the pneumonia of infants, may, for a while, cause embar- 
rassment. 

Prognosis. Epidemic cerebro-spinal meningitis is a dangerous 
disease. Eecovery from the fulminant variety can hardly be expected. 
A cautious opinion, even in the mildest form of the disease, is advis- 
able. General convulsions, incessant vomiting and the comatose 
condition are unfavorable signs. 

Treatment. The rational employment of the so-called antiphlo- 
gistic measures is still in favor with many experienced physicians, 
probably from the conviction that in acute meningeal inflammation 
the resources of our art can hardly offer anything better. Very little, 
if anything, can be done in those virulent cases that speedily tend to 
a fatal termination. Venesection is only indicated in intense cerebral 
congestion. Local abstraction of blood affords relief to the headache. 
Layers of leeches, according to the urgency of the symptoms, should 
be repeatedly applied to the temples and behind the ears. Cups are 
better adapted for the spine. At a later period, some good effects 
may be expected from blistering the nape of the neck. Cold, by 
means of the ice-helmet, should be unremittingly applied to the head 
so long as the patient will tolerate its use. 

Opinions differ in regard to the efficacy of mercury in this disease. 
My experience induces me to place much confidence in this remedy. 
I have seen good results from frequently repeated doses of calomel, 
until the gums become slightly affected. 

Active purgation may be of service in the beginning, but must not 
be kept up. 

Quinia appears to have no controlling influence in this disease. Its 
antipyretic properties, however, may be of service when the temper- 
ature is excessive. 

Opium and its preparations are of decided benefit, not only in allay- 
ing the pain in the head and promoting sleep, but also in exerting a 
favorable influence on the course of the disease. Prof. Stille, who is 
a great advocate of the opium treatment, recommends one grain of 
the narcotic every two hours, and, in severe cases, the same dose 
every hour. 



CHAPTER VIII. 
DISEASES OF THE SPINAL CORD. 

Myelitis. 

The inflammatory process in myelitis involves the substance of the 
cord to the exclusion of the meninges. Either the parenchymatous 
or the interstitial tissue may be primarily affected. According as the 
pathological changes vary in extent and situation they are of a dif- 
fused, circumscribed or disseminated character. Myelitis occurs as 
an acute and chronic affection. In regard to its etiological factors, 
the disease is divided into primary and secondary myelitis. 

Acute Myelitis. 

Anatomical Changes. The inflamed portion of the cord is changed 
in color and consistence, corresponding to different grades of soften- 
ing, which sometimes amount to complete breaking down of the 
tissue. In some instances the affected parts appear thickened or 
shrunken and atrophied. The different shades of color presented by 
the softened parts depend upon the variable quantity of blood with 
which they are mixed. In the majority of cases the softening is 
most intense in the central grey matter. The morbid alterations are 
usually well marked in the dorso-lumbar region. 

The microscopical appearances in the softened tissue consist of 
compound granule corpuscles, fat globules, pigment cells, free nuclei 
and degenerated nerve fibres and cells. In the early stage, before 
softening has taken place, the following anatomical changes are 
observed. The bloodvessels are dilated and sometimes covered by a 
granular exudation. Considerable alterations are noticed in the 
nervous elements. The nerve fibres appear thickened, and the axis 
cylinders show varicose swelling. The nerve cells are enlarged and 
rounded, or shrivelled and wasted; but the greatest pathological 
interest attaches to the presence of the nucleated granule cells (so- 
called exudation cells), which are derived from the neuroglia, and 



80 MANUAL OF NERVOUS DISEASES. 

indicate the implication of this tissue in the inflammatory process. 
They are found in all forms and stages of myelitis. 

The diffuse form of myelitis is characterized by the spread of the 
disease in the ascending and descending direction. In cases of this 
kind, the sciatic nerve and the muscles to which it is distributed are 
found in a state of fatty degeneration. 

Clinical History. The symptomatology of acute primary myelitis 
agrees in all essential points with that of traumatic myelitis, which 
is by far the more common form of the disease. It is understood 
that the term acute, when applied to myelitis, expresses the sudden 
development of the symptoms, irrespective of their longer or shorter 
duration. 

An attack of primary acute myelitis is usually ushered in by a sen- 
sation of tingling or numbness of the parts that eventually become 
paralyzed. Sometimes there is merely a feeling of tiredness and stiff- 
ness in the limbs. Shooting pains and cramps in the muscles are not 
uncommon. Other cases begin with a disagreeable sensation of 
weight and pressure in the back, bladder and rectum, or there is only 
an uncontrollable restlessness. 

Paraplegia is typical of the full development of acute myelitis. In 
the vast majority of cases the lower extremities are alone affected, 
owing to the most frequent implication of the inferior portion of the 
cord. The upper extremities are also paralyzed when the cervical 
region of the cord is the seat of the disease. Hemiplegia of spinal 
origin is of exceptional occurrence. In severe cases the paralysis of 
motion and sensation is complete. The patient has lost all power of 
movement in the extremities. There are, however, different grades of 
paralysis, proportionate to the extent and intensity of the pathological 
changes. Frequently the ability to raise the limbs to a slight extent 
is still retained, and, in cases of moderate severity, the patient can 
move them freely about in bed. Should he be able to walk with or 
without the assistance of crutches, it is noticed that his limbs tremble 
and the feet " drag." 

Paraplegic anaesthesia of the same distribution as the motor 
paralysis is nearly constant in acute myelitis. Complete loss of 
the cutaneous sensibility is the rule. In some cases the patient 
complains of spontaneous pains in the limbs, causing reflex spasms 
of the muscles. A rather common symptom is a feeling of 
constriction about the waist as if a belt were drawn tightly around it. 



DISEASES OF THE SPINAL CORD. 81 

The reflex excitability of the cord is usually diminished when the 
lumbar segment is involved; it is sometimes increased when the 
upper dorsal or cervical portion is alone affected. Its complete 
obliteration at the onset of the disease, or its gradual loss in pro- 
tracted cases, gives a bad prognosis. 

The electro-muscular contractility of the paralyzed muscles remains 
normal for a considerable length of time. Toward the close of the 
disease it diminishes until it is completely abolished. 

Atrophy of the affected muscles is only noticed in very severe 
cases. As a rule they retain their volume to a late stage of the 
disease. The sphincters at the commencement show signs of irrita- 
bility, the evacuation of the bladder being attended by a straining 
effort, and there is frequent retention of urine. At a later period, 
incontinence takes place, which eventually leads to cystitis. Obstinate 
constipation of the bowels or tenesmus, and finally involuntary 
discharge of the feces, result from simultaneous paralysis of the 
sphincter of the rectum. In men the virile power becomes feeble or 
is entirely lost. 

Bed sores are common in all forms of myelitis. They often develop 
from vesicles which appear on parts of the skin which are not subject 
to pressure. This evidently shows that the decubitus is due to 
trophic disturbance. The cedematous swelling of the extremities 
must be ascribed to the same cause. 

The temperature of the affected limbs is lowered, but cases are 
on record in which it was much increased at the beginning of the 
disease. 

The brain remains unaffected, except in cases where the degen- 
erative changes invade the upper portion of the spinal cord. If 
cerebral symptoms develop in ordinary acute myelitis, they probably 
result from pyasmic infection or ursemic poisoning. 

The course of acute myelitis varies with the seat, extent and 
progressive tendency of the morbid process. Its most frequent 
termination is either complete or incomplete paralysis. This may 
remain stationary, or eventually prove fatal from the extension of the 
disease in an upward direction, or from serious complications. Paresis 
of the upper extremities, embarrassment of respiration, difficulty of 
deglutition, and pupillary changes indicate the spread of the destruc- 
tive changes to the cervical region and beyond it. 

Etiology. Idiopathic acute myelitis is usually attributed to the 
combined effects of cold and dampness to which the spine is exposed, 



82 MANUAL OF NERVOUS DISEASES. 

to violent physical efforts, or excessive sexual indulgence. Cases have 
been known to follow some strong emotional disturbance, especially 
terror (Emotional paralysis). Traumatic myelitis and that form 
known as the "railway spine," agree in the main with the clinical 
history of acute myelitis. The myelitis from compression develops 
when caries of the vertebrae or intra-spinal tumors suddenly set up 
structural changes in the cord of an inflammatory character. 

Diagnosis. The differential diagnosis between primary and secon- 
dary acute myelitis is not always easy. Fracture of the vertebrae may 
not be recognizable ; and the existence of an intra-spinal tumor can 
at best be only surmised. It is well to remember that the rapid 
development of complete paraplegia, usually attended by the symptoms 
of shock, is significant of hemorrhage in the cord, whether of spon- 
taneous occurrence or following a traumatism or coming from a tumor 
within the spinal canal. The diagnosis of acute myelitis is obscured 
by its frequent complication with spinal meningitis, though it is not 
difficult to assign the symptoms proper to each of these affections. 

Prognosis. The prognosis of acute myelitis can be inferred from 
what has already been stated. This may be summarized as follows : 

The prognosis is favorable when the paralysis is incomplete or 
partial ; when the sphincters are little or not at all affected ; when 
the reflex excitability of the cord and the electric reaction of the 
muscles remain normal; when the paralysis rapidly improves and 
bed sores take on the healing process. 

It is unfavorable when the upper portions of the cord are involved ; 
when the paralysis is complete and does not improve, and when the 
sphincters are much enfeebled. The early appearance of bed sores, 
but more especially the development of cystitis, for bode danger to the 
patient. 

Treatment. In recent cases of traumatic myelitis, local abstraction 
of blood, followed by the application of the ice-bag near the seat of 
injury, may be tried with the intention of subduing the inflammation. 
This active treatment should not be continued too long. Brown- 
Sequard recommends in its place the administration of ergot and 
belladonna. The older surgeons were much in favor of the bichloride 
of mercury in traumatic myelitis. Iodide of potassium is, however, 
a safer remedy. Blistering is advisable at a later period. Dr. 
Eadcliffe expects better results from the tincture of chloride of iron, 
which he thinks has a tendency to counteract the low inflammatory 



DISEASES OF THE SPINAL CORD. 83 

process characteristic of acute myelitis. There is a general agree- 
ment, however, to trust more to the curative influence of rest than to 
any special medication. The patient should be strictly forbidden to 
leave his bed for the first three months. For the same reason the 
ill-advice of officious friends that he be encouraged to take active 
exercise, must be opposed. Besting upon the side is preferable to 
the recumbent position. 

Attention to the functions of the bladder is urgently required 
throughout the whole course of the disease. In retention of urine, 
nothing can replace the prompt use of the catheter. Bed sores are 
sometimes prevented or at least stayed for a considerable time, by 
properly adjusting the bed-clothes so as to avoid the formation of 
folds and wrinkles. A general supporting and tonic treatment 
should be early begun. The patient should be allowed a nutritious 
diet, and take quinia, iron and cod- liver oil. The iodide of potassium 
may be given alternately with these tonics. At a later period a trial 
may be made with strychnia; but this remedy must at once be 
abandoned when it lights up inordinate reflex excitability. The same 
rule must be observed when electricity is employed. Mild cases are 
sometimes benefited at the onset by the constant current; but 
generally it is advisable not to be too hasty with this therapeutic 
agent. Patieuts derive great comfort from gentle friction of their 
paralyzed limbs, and this is all the good that the reputed liniments can 
accomplish. The stimulative effect of warm baths proves injurious 
when incautiously ordered at an early date of the disease. There is, 
however, no doubt that many paraplegic invalids have derived benefit 
from the use of the Hot Springs of Arkansas and the Hot Sulphur 
Baths of Virginia. It is well to excite the nutrition of the paralyzed 
muscles by kneading and the application of faradism. 

Chronic Myelitis. 

This heading includes a large class of spinal affections, some of 
which undoubtedly depend upon a slow and insidious inflammation 
of the cord, whilst the pathology of others is still undetermined. 
Paraplegia, more or less complete, is a symptom common to all of 
them. 

The Anatomical Changes in cases of primary chronic myelitis 
embrace disintegration of the nerve elements and nerve roots, 
proliferation of the neuroglia and thickening of the coats of the 



84: MANUAL OF NERVOUS DISEASES. 

bloodvessels. A fine vascular network replaces the grey substance. 
Transverse sections of portions of the cord present the appearance of a 
finely granular substance, which Lockhard Clarke describes as " grey 
degeneration " of the cord. In some cases the cord becomes indurated, 
which causes destruction of the nerve tissue. 

Clinical History. A noteworthy fact in the early history of chronic 
myelitis is the apparently insignificant character of the symptoms, 
that gradually give way to the development of the more reliable 
signs which mark the disease. At first there may be merely vague, 
wandering pains and a sensation of numbness, tingling or creeping 
in the lower extremities. The pains, which occasionally become 
aggravated and often affect also the back and loins, are likely to be 
mistaken for rheumatism. Many patients experience an unaccount- 
able sensation of fatigue while standing or walking; they take 
frequent rests and seek support when on their feet, which " drag " as 
they move along. Frequently there is a feeling as if the legs were 
" asleep," and a sensation of constriction about the waist. A greater 
length of time is occupied in urinating than formerly, and there may 
be " dribbling." Impairment of the sexual function is evidenced by 
imperfect erections and premature ejaculations. 

As the disease advances in the transverse direction of the cord, more 
or less of the central grey matter becomes involved. The motor and 
sensory disturbances hold even pace with the depth and the extension 
of the destructive changes. The paraplegia, the implication of the 
sphincters, the enfeeblement or loss of the sexual function, and all 
the adventitious phenomena which were described as constituting 
the symptomatology of acute myelitis, are reproduced in the chronic 
form of the disease. 

Etiology. With the one exception of violent injury, every cause 
that was enumerated in connection with acute myelitis favors the 
development of chronic parenchymatous inflammation of the cord. 
It mainly depends upon the sudden or slow action of the exciting 
cause whether one or the other shall develop. Some of the para- 
plegias of an uncertain pathology require a brief consideration. 

Hysterical Paraplegia. 

Briquet met with 18 cases of paraplegia in 113 hysterical patients 
who suffered from different forms of paralysis. The presumptive 
evidence of the hysterical character of the paralysis rests upon its 



DISEASES OF THE SPINAL CORD. 85 

conjunction with other symptoms of a decided hysterical nature. 
But hysterical paralysis presents some peculiar features which 
greatly assist the diagnosis. As a rule the paralysis is incomplete, 
and associated with anaesthesia of a marked kind. The muscles have 
lost their electro-sensibility, while their electro-muscular contractility 
remains intact. The sphincters suffer less than in ordinary transverse 
myelitis, but owing to an abnormal sensibility the bladder is irritable, 
and retention of urine, probably due to reflex action, is liable to occur. 

Syphilitic Paraplegia. 

Paraplegia of a syphilitic nature may be suspected when signs of 
the constitutional disease are present, and no other palpable cause of 
the paralysis can be assigned. The result of antisyphilitic treatment 
is, however, of the greatest diagnostic importance. But even this is 
not conclusive, for an ordinary myelitis sometimes yields to potassium 
iodide. 

Paraplegia after Acute Diseases. 

Paraplegia, as well as other forms of paralysis, is now and then 
observed to occur during the convalescence of acute infectious 
diseases. Spinal paralysis has been known to follow diphtheria, 
smallpox, scarlatina, measles, erysipelas and typhoid fever. It is 
hardly to be supposed that an actual lesion of the cord underlies 
these forms of paralysis, as they show a tendency to disappear spon- 
taneously. 

Reflex Paralysis. 

By this term is understood a paralytic affection which is due to 
the influence of an irritation existing in a remote part — usually the 
urinary, uterine or intestinal apparatus. Although many of these 
supposed examples of reflex paralysis frequently turn out to result 
from actual lesion of the cord, there are others in which such a 
relation cannot be shown to exist. Brown-Sequard's theory of reflex 
paralysis assumes an anaemic condition of the cord, induced by reflex 
action of the distant source of irritation that causes constriction of 
the spinal bloodvessels. Leyden refers the paralysis to an ascending 
or migrating neuritis. 

The treatment must be directed to the removal of the ascertained 
exciting cause; but the paralysis sometimes persists in spite of the 
disappearance of the primary affection. 



86 MANUAL OF NERVOUS DISEASES. 

Treatment of Chronic Myelitis. To avoid unnecessary repetitions, 
it may be broadly stated that the indications of treatment in chronic 
myelitis and its allied affections are the same as in acute myelitis ; 
but, with these exceptions, the local abstraction of blood may be 
omitted; a course of electric treatment should be begun at once, 
and the patient be allowed to take gentle exercise. 



Acute Ascending Paralysis (Landry's Paralysis). 

This is a rare form of spinal paralysis. Its etiology is obscure, 
though the disease has been known to succeed smallpox, diphtheria 
and pneumonia. The paralysis extends in an upward direction, 
affecting first the lower and then the upper extremities. When the 
disease involves the medulla oblongata it speedily proves fatal. 
There is no anaesthesia, and the electric excitability remains normal. 
Post-mortem examinations have thus far discovered no lesions in the 
cord to account for the paralysis. Disturbances of respiration and 
deglutition are of the gravest import. The disease suggests the 
treatment of acute myelitis. 

Anterior Acute Polyomyletis (Infantile Spinal 
Paralysis). 

This disease was described by the older writers under the name of 
" the essential paralysis of children." In the greater number of cases 
the onset is sudden and marked by a high grade of fever. Paralysis 
of the lower extremities rapidly develops. There is no loss of 
sensibility, nor implication of the sphincters. Improvement of the 
paralysis is soon established, but certain isolated muscles or groups 
of muscles seldom regain their normal motility. They finally waste, 
and, in consequence, deformity of the affected limb takes place. 

Anatomical Changes. The meagre accounts concerning the ana- 
tomical changes at an early period of the disease relate to evidences 
of a diffuse inflammation almost exclusively confined to the anterior 
grey horns of the lumbar or cervical enlargement of the cord. At a 
later stage these parts are found wasted and shrunken. The antero- 
lateral columns present similar pathological alterations; but the 
most important structural change in the anterior grey horns is the 
disappearance of many of the multipolar ganglionic cells. The 



DISEASES OF THE SPINAL CORD. 87 

corresponding anterior roots of spinal nerves exhibit signs of 
secondary degeneration. 

Clinical History. Acute symptoms of very short duration (fever, 
delirium, and, in small children, general convulsions) usher in the 
paralysis in the greater number of cases. Sometimes there is an entire 
absence of the acute stage. The child on waking up in the morning 
is found to be paralyzed, or the loss of motility is gradually established. 
Very soon the paralysis becomes limited to one of the upper or, far 
more frequently, to one of the lower extremities. It is not unusual 
for the circumscribed paralysis to affect only certain groups of muscles. 
The muscles supplied by the peroneal nerve appear to be the favorite 
seat of the paralysis. Whatever may be the extent or severity of the 
paralysis, considerable improvement takes place after the lapse of a 
few weeks, and sometimes speedily terminates in recovery. But 
complete restoration can hardly be expected if the paralysis remains 
stationary for months. By this time the affected muscles begin to 
show evidences of atrophy. The muscular wasting appears to come 
on independently of the paralysis, for the nutrition of the bones also 
suffers ; their growth is arrested, and finally the stunted, withered 
limb may be reduced to a useless appendage of the body. Various 
deformities result from the want of antagonism in the paralyzed 
limbs — " club-foot," " knock-knee," " high shoulder," etc. A peculiar 
relaxed condition of the ligaments of the joints, favored by the lack 
of muscular support, interferes much with locomotion. 

The paralyzed muscles show diminished reaction to both currents; 
but the faradic contractility is found abolished in the muscles which 
are much affected, while the galvanic contractility has not entirely 
disappeared. 

Etiology. Infantile spinal paralysis usually occurs between the 
ages of one and four years. Nothing definite is known respecting 
the influences that predispose to the development of the disease. 
Children in previous good health are as likely to be affected as those 
of a delicate constitution. It is doubtful whether the period of 
dentition acts as a predisposing cause. I have seen one instance in 
which "catching cold" brought on the paralysis. The case was that 
of a weakly boy of about three years of age, who was made to undergo 
the "hardening process " of sitting on the cold wet grass immediately 
after a warm bath. 



88 MANUAL OF NERVOUS DISEASES. 

Diagnosis. Signs of a retarded development in small children 
occasionally come under notice which may be confounded with some 
of the phenomena characteristic of infantile spinal paralysis. These 
little patients are slow in learning to walk, and a helplessness and 
awkwardness in their movements persist for a considerable period 
during their growth. There is, however, no fever, no actual paralysis 
nor muscular atrophy. 

The paralysis attending acute cerebral affections in children 
apparently assumes, in some cases, the spinal type. To make the 
distinction, it needs only to be remembered that the violent "head 
symptoms," the pupillary changes, the vomiting, the stupor and coma, 
constitute a group of morbid phenomena which is not encountered 
in the spinal paralysis of children. 

Progressive muscular atrophy is distinguished by the following 
diagnostic points : This disease begins in a slow, chronic manner ; 
there is no febrile excitement ; the wasting affects symmetrical 
muscles, and the incomplete paralysis develops gradually. 

The temporary paralysis of children, described by Kennedy, 
results from exposure, or compression of the limbs. That this affec- 
tion is of a purely myopathic character is shown by the integrity of 
the nutrition of the muscles and the normal electrical excitability. 
The paralysis disappears in the course of a few weeks. 

Prognosis. Spontaneous improvement of the paralysis up to a 
certain point may be confidently expected in nearly every case. But 
this favorable tendency to recovery appears to depend upon the 
restoration of parts of the cord which were but slightly affected by 
the lesion. The probability of further improvement must be judged 
by the condition of the muscles and their behavior to the electric 
current. 

Treatment. Galvanisation holds out the best prospect of success. 
The application should begin at the close of the second or third week. 
At first a current of moderate strength should be passed from the spine 
to the nerves and muscles, and at a later stage a current of increased 
intensity may be used. Local faradisation, assisted by massage and 
friction, helps to stimulate the paralyzed muscles. In many cases it 
will be found necessary to apply an orthopedic apparatus to facilitate 
walking. 



CHAPTER IX. 

SYSTEMIC DISEASES OF THE SPINAL CORD. 

The diseases of the spinal cord which will be considered under the 
above head differ in many particulars from ordinary myelitis. 
Unlike the latter, in which the transverse section of the cord is more 
or less involved, they are distinguished by anatomical changes which 
are limited to definite portions of this organ. The uncertainty of 
the nature of the pathological processes that underlie the morbid 
alterations of this class of spinal affections, is evidenced by the 
uncompromising terms, sclerosis and degeneration, that are employed 
to designate them. 

Progressive Loco-Motor Ataxy (Tabes Dorsalis). 

This is a chronic disease affecting the posterior columns of the 
spinal cord, and is clinically characterized by incoordination of 
movements, while the gross muscular power remains intact. 

Anatomical Changes. Transverse sections of the cord present a 
grey gelatinous mass, which occupies the space between the posterior 
horns. The cut surfaces appear wasted and sunken. The posterior 
horns are frequently involved in the same grey degeneration. This 
morbid change is usually most pronounced in the lumbar division of 
the cord. 

Microscopic examination shows that the affected parts of the 
posterior columns are changed into a network of fine and dense 
filamentous tissue from which the nerve-fibres have more or less 
disappeared. In the most degenerated portions only a few of these 
fibres are visible, which merely consist of atrophied axis cylinders. 
In some places the fibres of the neuroglia are of a firm consistence 
and present a wavy appearance. This apparently new formed tissue 
contains an abundance of round or oval nuclei and corpora amylacea, 
also a few stellated bodies, and only occasionally compound granule 
cells. The coats of the large arteries are thickened and interspersed 
with pigment cells and granular fat. The grey substance near the 



90 MANUAL OF NERVOUS DISEASES. 

entrance of the posterior roots nearly always participates in the 
degeneration. Clarke's columns appear atrophied, but the cellular 
elements remain intact. Atrophy of the optic nerve is sometimes 
observed, and in rare instances there is a slight shrinking of some of 
the nerve trunks. 

Etiology. Loco-motor ataxy has, in some cases, been traced to the 
immediate effects of exposure to cold and dampness. It is highly 
probable that venereal excesses occasionally develop the disease. 
Syphilis has also been blamed, and probably with good reason. Men 
in the middle period of life are especially liable to be affected. 

Clinical History. It is convenient to divide the clinical history of 
loco-motor ataxy into three stages, although the wide range of the 
functional disturbances and the irregularity of their appearance 
hardly justify such an arrangement. 

The Neuralgic Stage. The disease usually begins with pains of a 
shooting, darting or " lightning " character, sometimes occurring in 
paroxysms or continuing for days and weeks. In the majority of 
cases the pains are confined to the lower extremities ; but the head, 
the trunk, the upper extremities or the back maybe alone affected. A 
sensation of numbness or formication is frequently felt in the painful 
parts. Weakness of the limbs and an unsteady gait become associated 
with the pains. Patients are apt to ascribe all these symptoms to their 
" rheumatism." A careful examination, however, will discover the 
presence of additional phenomena even at this early stage. Very 
commonly the genito- urinary functions are in an irritable condition. 
There is a distressing sensation of constriction around the trunk and 
limbs as if they were tightened by a band ; some degree of ana3sthesia 
particularly evident in the fingers ; dimness of vision of one or both 
eyes and a paretic condition of some of the ocular muscles. The 
disturbances of vision often disappear. These ill-defined symptoms 
extend, perhaps, over a number of years, and are usually misunder- 
stood, until others of a more marked character reveal their true nature. 

The Ataxic Stage. At this stage the peculiar incoordination of 
movements signalizes the complete establishment of the disease. 
All the movements showing this motor disturbance partake of an 
unsteady, vacillating and impulsive character. Even in the lighter 
forms some uncertainty in the step or irregularity of locomotion is 
observed. In noticing the position of the legs it will be seen that 



SYSTEMIC DISEASES OF THE SPINAL CORD. 91 

they are held too wide apart; the knees are but little flexed; the 
limbs are hurled forward or sideways, and the feet, which are raised 
too high, come down in a stamping fashion. There is evidently an 
insecure, disorderly adjustment of associated muscular movements; 
they are excessive and badly controlled. The body reels and is in 
momentary danger of losing its equilibrium. If the patient attempts 
to run he will find it difficult to come to a stop. On making a short 
turn he is apt to trip. He carefully watches his movements and 
constantly directs his eyes to every step he takes. Before very long 
he requires the assistance of a cane, and eventually crutches become 
indispensable. 

The final, or paralytic, stage is reached when the muscles refuse to 
contract in the effort of the patient to assume the erect position. 
Bed-sores make their appearance, emaciation increases, the muscles 
atrophy and the sphincters become enfeebled. The cerebral functions 
remain unaffected to the end. 



Analysis of the Symptoms. 

The Ataxic Disturbance. An interesting point in connection with 
this most significant symptom of the disease is the remarkable 
influence exerted by the sense of sight. When the patient closes his 
eyes in the acts of standing and walking, his body begins to totter 
and oscillate as if he were unable to sustain his center of gravity ; 
and if the ataxia is of an aggravated character he at once falls over 
as soon as the sight is withdrawn. The upper extremities are usually 
much less affected. There is a want of precision and an appearance 
of awkwardness in their movements. This is particularly noticeable 
when manipulations are attempted that require some nicety in their 
execution, such as buttoning a sleeve or threading a needle. 

The Reflexes. There may be no diminution of the reflex excitability 
of the skin, but it is remarkable that the tendon reflexes in typical 
cases of ataxia are abolished. To test the " knee jerk," the individual 
is requested to cross one leg over the other at the knees so that the 
upper limb hangs loosely downward. A slight tap on the patella will 
in healthy persons evoke a more or less vigorous movement of the 
limb. The abolition of the " knee phenomenon " in loco-motor ataxy 
is a symptom of great diagnostic importance. 



92 MANUAL OF NERVOUS DISEASES. 

Anaesthesia. There are few well-marked cases of ataxia in which 
this symptom is wanting. At least some of the different qualities of 
common sensation will be either found blunted or entirely abolished. 
Loss of tactile and muscular sensibility is common, and this explains 
the phenomenon why patients are unable to tell the position of their 
limbs when in bed or in the dark. On the other hand, there is an 
abnormal sensitiveness to changes of temperature. A more constant 
and obtrusive symptom than anaesthesia is an abnormal sensation 
of the nature of numbness. Patients compare it to a feeling of 
furriness at the soles of the feet, as if they were standing on a soft 
cushion or a bag filled with air. In the hands the sensation simulates 
the impression of being covered by gloves. 

The Genito-urinary Symptoms. Signs of irritation of the bladder, 
as has already been mentioned, belong to the earlier stage; but as the 
disease progresses, the frequency and urgency of micturition give 
way to incontinence with all its serious consequences. The sphincter 
of the rectum suffers less. 

Increase of sexual excitement has been noticed at the commence- 
ment of the disease ; finally, however, complete impotence supervenes. 

Trophic Disturbances. The friability of the bones in ataxic 
persons must be attributed to trophic changes. Charcot has drawn 
attention to a form of joint disease, usually affecting the knee, which 
is probably of a similar origin. 

" Crises Gastriques." Intercurrent attacks of gastralgia, nausea 
and vomiting, are not seldom observed during the course of the 
disease. 

Explanation of the Symptoms. In view of the distinctive lesion 
that characterizes loco-motor ataxy, it might, at first sight, be thought 
an easy task to propose an adequate theory of this disease. But such 
is not the case. No doubt the pain and the anaesthesia must be 
ascribed to the pathological changes in the posterior columns and 
nerve roots. But our imperfect knowledge of the physiology of the 
spinal cord is evidenced by the difficulty of adequately explaining 
the essential symptom of the disease — the ataxic movements. There 
are no evidences to show that the cord contains centers of coordination. 
Leyden refers the symptoms of incoordination to the anaesthesia 
resulting from the degenerated condition of the posterior columns and 
nerve roots ; for it is well known that motor functions are materially 



SYSTEMIC DISEASES OF THE SPINAL COED. 93 

influenced by sensitive impressions. It is objected that ataxic move- 
ments may exist without defect or loss of sensibility, and conversely 
that disease of the posterior columns of the cord is not always attended 
by symptoms of incoordination. Brown-Sequard arrives at the 
conclusion that the destruction of the nerve fibres which connect the 
posterior and anterior roots disturbs the reflex mechanism which is 
engaged in the acts of walking and standing. This theory presupposes 
the implication of the grey substance. 

It may be broadly assumed that the starting point of the disease 
is the existence Of a parenchymatous degeneration of the cord, 
probably of an inflammatory character. The pathological changes, 
as judged by the order of the morbid phenomena, progress both in 
a longitudinal and transverse direction, causing the functional 
disturbances that constitute the symptomatology of the disease. 

Diagnosis. A typical case of loco-motor ataxy presents such clearly 
cut clinical features that it can be easily distinguished from any 
other form of spinal disease. The differential diagnosis is attended 
with difficulties in those mixed cases in which the symptoms of 
ordinary myelitis complicate the ataxic phenomena. At an early 
stage when the signs of incoordination are wanting, and only the 
sensory disturbances, the pain and anaesthesia represent the disease, 
the diagnosis will be rendered doubtful. It is well to rememher, 
however, that the existence of a double sciatica should direct 
attention to the spinal cord, and those tests should be tried which 
are likely to elicit ataxic symptoms. 

Prognosis. Experience confirms the bad prognosis which must 
a priori be entertained of a disease which is marked by progressive 
destructive changes. Still the forecast need not be so absolutely 
gloomy, for loco-motor ataxy assumes sometimes a very mild character, 
and under favorable circumstances the extent and severity of the 
morbid alterations may be checked. There are patients who survive 
for many years ; and, though recovery cannot be expected when the 
disease is once fully established, yet by the avoidance of those habits 
and indulgence which are detrimental to the general health, and 
the employment of remedies for the relief of the pains and the vesical 
irritation, the hope of prolonging life may be reasonably entertained. 

Treatment. The early recognition of the disease, which our better 
acquaintance with its initiatory symptoms has now rendered easy, 



94 MANUAL OF NERVOUS DISEASES. 

affords the opportunity of adopting those measures that tend to arrest 
its progress. Above all things the patient should consider himself 
an invalid and abandon any avocation which calls for active physical 
exertions. The benefit derived from change of occupation I have 
lately witnessed in the case of a man who was daily engaged in 
loading and unloading heavy packages at a railway depot, and who 
was in the habit of taking a rest by lying down on the cold and 
damp flooring of the building. The paroxysms of atrocious pains 
in his lower extremities, the irritability of his bladder, and the 
commencing unsteadiness of his gait remarkably improved from the 
time that he quit work. He was ordered to take gentle outdoor 
exercise in favorable weather and to abstain from sexual indulgence. 
The practice of applying moist cups, or the actual cautery, to the 
spine has yielded no encouraging results. Many observers speak 
favorably of the hydropathic treatment. This may be carried out at 
home by sponging the spine, but the water should be of a moderate 
temperature. Thermal baths are not advisable. Potassium iodide 
deserves a . trial at an early period. Nitrate of silver stands in 
greatest repute in this disease. The dose should be gradually 
increased, and the usual caution observed to prevent bronzing of the 
skin. Strychnia has not been found of benefit, though it is certainly 
indicated in ocular paralysis. Ergot is recommended by Brown- 
Sequard. Hammond saw benefit from the administration of ter- 
chloride of gold. The free employment of anodynes for the mitigation 
of the eccentric pains cannot be avoided. Weir Mitchell speaks in 
favor of absolute rest. 

Multiple Sclerosis of the Brain and Spinal Cord 
(Sclerose en Plaque). 

Anatomical Changes. The lesion characteristic of this disease 
consists of a number of translucent, yellowish or greyish patches of 
firm consistence and of variable size which affect different portions of 
the brain and spinal cord. They are sometimes found in the medulla 
oblongata, the cerebellum, the basal ganglia, the pons, the cerebral 
peduncles, the optic nerve and in the trunks of peripheral nerves. 
When the sclerotic patches are limited to the brain, they involve by 
preference the white substance of the hemispheres and the nuclei of 
the cranial nerves arising from the floor of the fourth ventricle. 

The plaques under the microscope are found to be composed of 



SYSTEMIC DISEASES OF THE SPINAL CORD. 95 

increased and thickened interstitial tissue and atrophied nerve 
elements. These morbid alterations are more marked in the center 
than at the periphery of the patches. Numerous nerve fibres are 
deprived of their medullary sheaths, the axis cylinders are shrunken 
and in some places they have entirely disappeared. The ganglionic 
cells resist the degenerative changes longer, but finally shrivel and 
many of them are destroyed. The bloodvessels are also implicated in 
the sclerotic process. Their coats are thickened and infiltrated with 
pigment granules and fat. The neuroglia is changed into an extremely 
dense mass of fibrous tissue where it surrounds and firmly compresses 
the remaining nerve elements. Compound granule corpuscles and 
corpora amylacea are constant constituents of the sclerotic patches. 
They contain, besides, a moderate number of oval nuclei and numerous 
stellated bodies of large size (Deiter's cells). 

Etiology. Sclerosis occurs most frequently between the ages of 
twenty and thirty years. According to the experience of Charcot, 
more females are affected by the disease than males. Duchenne 
reports a case attributable to hereditary influence. Among the sup- 
posed exciting causes the following may be mentioned : exposure to a 
damp atmosphere; physical over-exertion; mental shocks; concussion 
of the body, and previous acute diseases. 

In respect to the pathogenesis of sclerosis, opinions are divided 
concerning the primary morbid process that underlies the lesion. 
There are weighty considerations in support of the view of Kindfleish, 
that the anatomical changes begin in the bloodvessels and, secondarily, 
implicate the neuroglia and the nerve elements. According to 
Leyden, the pathological process of sclerosis is of the nature of an 
interstitial chronic myelitis, which at first affects the neuroglia and 
finally involves the nerve elements. 

Clinical History. In consequence of the very gradual development 
of sclerosis, it is only after the disease has made considerable progress 
that prominent symptoms make their appearance. When the lesion 
affects the brain first, no reliable conclusion can be drawn in reference 
to the source of the cerebral irritation. And, likewise, when the spinal 
cord is the starting point of the degenerative process, which happens 
in the majority of cases, nothing definite can be inferred from the 
existence of mere muscular weakness of the lower extremities. 
Occasionally the manifestations of sclerosis date from an apoplectic 
or convulsive seizure. Sensory disturbances are but rarely witnessed 
throughout the whole course of the disease. 



96 MANUAL OF NERVOUS DISEASES. 

Of great significance is a peculiar tremor which affects the patient 
whenever he attempts to carry out a movement. It ceases as soon as 
he relinquishes the effort. Thus, on rising from his seat or moving 
his limbs, the trembling at once begins. Upon grasping a glass of 
water to bring it to his lips, the arm is seized by a violent shaking 
which spills the fluid, and if he succeeds in carrying the glass to 
his mouth it clatters against his teeth. Oscillation of the eyeballs 
(nystagmus) is observed in about half the cases. This is also a 
symptom of motor irritation like the tremor. 

A singular defect of speech is a constant symptom in the cerebro- 
spinal form of the disease and is of great diagnostic value. Words 
are pronounced in a hesitating, drawling manner, a pause being made 
as in scanning between each syllable. 

The act of walking imposes considerable effort on the patient and 
quickly tires him out. There is an awkward, shovelling kind of 
gait, and, in some cases, the erect position cannot be maintained 
without some support. At a later stage, or in severe cases at an 
early period, walking becomes simply impossible. The muscles, 
especially the flexors and abductors of the thigh, are suddenly seized 
with a remarkable rigidity that foils for a time the efforts at 
locomotion. Finally the flexors become similarly affected, causing 
permanent contractures, so that the heels touch the nates or the 
thighs remain bent upon the trunk. Dorsal or eccentric pain is not 
a conspicuous, or at least not a constant symptom of sclerosis. 
Formication of the extremities is rather more common. Disturbances 
of vision, chiefly amblyopia and diplopia, depending upon partial 
paralysis of ocular muscles, are of an evanescent character. 

Occasionally some of the patients break out in fits of sobbing and 
crying without an assignable cause. 

The sphincters are seldom enfeebled, and the sexual functions in 
the majority of cases remain unimpaired. 

Although a typical case of multiple sclerosis is easily recognized, 
yet it is well to bear in mind that its symptomatology varies in 
accordance with the extent and distribution of the lesion. Sclerosis 
of the medulla oblongata gives rise to a very serious set of symptoms. 
There is paralysis of the tongue, difficulty of deglutition and embar- 
rassment of the respiration. Psychical and motor disturbances 
identical in character with the peculiar combination of symptoms 
distinctive of general paralysis of the insane, not infrequently develop 
at a late period of the disease. 



SYSTEMIC DISEASES OF THE SPINAL COED. 97 

The symptoms of an ordinary myelitis develop in the event of the 
spinal cord being affected by central sclerosis. 

Diagnosis. Sclerosis is more likely to be confounded with paralysis 
agitans than with any other affection of the brain or spinal cord. 
There is certainly much resemblance between the tremors that 
characterize both diseases. The distinction rests on the circumstance 
that the tremor of sclerosis is only evoked when the patient makes a 
movement, while the tremor of shaking palsy is continuous, whether 
the patient is in motion or at rest. Another distinguishing feature 
is the difference in' the time of life at which these diseases develop. 
Sclerosis is an affection of the early period of life ; paralysis agitans 
attacks persons of an advanced age. 

The irregular and grotesque movements of chorea can hardly be 
likened to a tremor. Choreic patients are spontaneously impelled to 
perform purposeless actions, which is not witnessed in sclerosis. 

There is only a superficial resemblance between ataxia and multiple 
sclerosis. A mistake is scarcely possible, considering the clinical 
peculiarities of these several affections. 

Prognosis. The only encouraging feature in the prognosis of 
sclerosis is the frequent improvement of the symptoms during the 
protracted course of the disease. Serious implication of the medulla 
oblongata speedily tends to a fatal termination. The average 
duration is about four years. 

Treatment. Therapeutics has hitherto met with little success in 
the treatment of sclerosis. If the earlier symptoms of the disease did 
not usually elude observation, considerable benefit might probably be 
derived from mild antiphlogistic measures. After the degenerative 
process is once established there is but faint hope to arrest its 
fatal tendency. The remedies which deserve some confidence are 
potassium iodide, nitrate of silver, cod-liver oil and strychnia. Great 
improvement of the symptoms has been observed from sea bathing 
and electricity. 

Spasmodic Spinal Paralysis (Lateral Sclerosis). 

Anatomical Changes. It is yet undecided whether the disease 
which Charcot attributes to sclerosis of the lateral columns, and 
which Erb describes under the name of " spastic spinal paralysis," 
is due to morbid changes analogous to " multiple sclerosis," or to a 



98 MANUAL OF NERVOUS DISEASES. 

pathological condition identical with the " secondary degeneration " 
of Tuerk. 

Clinical History. The essential symptoms of the disease consist 
of muscular weakness of the limbs in the early stage, and spasmodic 
rigidity, especially of the lower extremities, at a later period. The 
paresis is evidenced by the sluggishness of movements and an unusual 
sense of fatigue, of which the patient complains after standing and 
walking. There is marked increase of the tendon reflexes. Twitching 
and stiffness of the affected muscles supervene, which seriously 
interfere with locomotion. The patient is liable to stumble over 
slight unevenness of the ground. He seems to walk on stilts, gets 
hold of objects to steady himself and, finally, is only able to hop about. 
As the disease progresses the rigid and spastic condition of the 
muscles increases, so that the limbs become fixed in the extended 
position. 

Diagnosis and Prognosis. Spastic spinal paralysis presents an 
assemblage of well-defined symptoms, which render its distinction 
from allied affections of the cord a matter of little difficulty. The 
muscular weakness and stiffness assume sometimes a hemiplegic 
character, which circumstance may for a while embarrass the 
diagnosis. But it must be remembered that the paresis starts in the 
lower extremities, there are no brain symptoms, and none of the 
cranial nerves are affected. From ordinary chronic myelitis it can be 
distinguished by the absence of disturbances of sensibility and by the 
integrity of the sphincters and the sexual functions. Loco-motor 
ataxia and progressive muscular atrophy occur as complications. 
The prognosis is more favorable than it is in other organic diseases 
of the cord. 

Treatment The therapeutics of this affection resolves itself into 
that of chronic myelitis. Central galvanisation and the cold water 
treatment take the first rank among the remedial measures. 
Strychnia is contraindicated. 

Progressive Muscular Atrophy (Wasting Palsy). 

Anatomical Changes. A peculiar wasting of muscles in different 
parts of the body was first recognized by Aran as a distinctive 
disease. But the first intimation of its morbid anatomy came from 
Cruveilhier, who declared it to be a spinal affection. For a complete 



SYSTEMIC DISEASES OF THE SPINAL COED. \)\) 

account of its symptomatology we are indebted to Duchenne. The 
results of later investigations tend to confirm the opinion that the 
fundamental lesion of progressive muscular atrophy consists of 
degeneration of the anterior grey columns. The changes under the 
microscope showed in some reported cases pigmentary atrophy of 
nerve cells of the anterior horns and the anterior nerve roots. The 
atrophied muscles exhibit marked anatomical changes. Their striae 
are indistinct, and many bundles of muscular fasciculi are of a pale ' 
color and of a gelatinous consistence. Normal muscular fibres are 
found alongside of others which have undergone fatty degeneration. 
In the most atrophied portion of muscles nothing is left but the 
empty sarcolemma. 

Secondary forms of progressive muscular atrophy develop from 
lesions of the cord that eventually involve the anterior grey columns. 
This complication has been observed in labio-glosso-pharyngeal 
paralysis, loco-motor ataxy, cerebro-spinal sclerosis, and in other 
examples of degeneration of the cord in which the primary lesion 
extended forward. 

Clinical History. The wasting in a typical case of progressive 
muscular atrophy begins in the hands and ringers. At first the ball 
of the thumb and then the hypothenar eminence disappear. On 
extending the hands, the fingers assume a claw-shaped appearance 
(main en griffe), in consequence of atrophy of the interossii, which 
keeps the last phalanges in a state of flexion. The atrophy next 
invades the wrist, the extensors of the forearm, and then the muscles 
of the shoulder and the back, causing flatness and depression of the 
shoulder. Travelling downward, the atrophy attacks the muscles of 
the trunk, and finally those of the lower extremities. 

The irregular order of the atrophy gives a characteristic appearance 
to the contour of the body. A muscle or part of a muscle wastes 
whilst its next neighbor remains unaffected. The bellies of the sound 
muscles strangely contrast with the groove left by the muscles that 
are wasted. Bones and tendons become prominent in situations where 
the volume of the muscles is diminished. 

Corresponding with the extent and intensity of the atrophy there 
is a functional weakness of the muscles which does not amount to 
true paralysis, though the patient is finally reduced to a pitiable state 
of helplessness. But for a long time he is still capable of carrying 
out movements by means of supplementary muscles that yet retain 
their structural integrity. A striking instance of this I observed 



100 MANUAL OF NERVOUS DISEASES. 

in the case of the so-called "living skeleton" who was exhibited in 
this city. When his head dropped on his shoulder he could swing 
it back again to the erect position by a violent jerk. On attempting 
to rise from his seat he had the trick of twisting his body, which 
brought him to his feet. 

Fibrillary twitch ings in the muscles occur early and constitute a 
notable symptom of the disease. Spasmodic contractions of muscles 
or groups of muscles are also occasionally witnessed. 

A dull, diffuse pain in the muscles, which ultimately become 
atrophied, is usually mistaken by the patient for " rheumatism." This 
pain is sometimes of a lancinating or boring character. To the 
subjective symptoms belong also a creeping sensation in the fingers 
and numbness of the hand and arm. But all these disturbances of 
sensibility are thrown into the background by the prominence and 
importance of the muscular wasting. 

Inequality of the pupils has been observed in a small number of 
cases, contraction more frequently than dilatation. 

Electric exploration of the diseased muscles yields very interesting 
results. In general it may be said that the electro-muscular 
contractility decreases in proportion to the intensity of the atrophy. 
So long as there are some muscular fibres left, a slight contraction 
can be obtained ; but a completely atrophied muscle, or one which is 
replaced by infiltrated fat, ceases to give responses to either current. 
Increased galvanic excitability has been noticed in some cases, but 
on the other hand, decided diminution of electric reaction is 
occasionally observable in muscles before they begin to atrophy. 

Etiology. Men in their best years, who are actively engaged in 
occupations that require hard labor, are the usual victims of wasting 
palsy. Charcot traced most of his cases to the influence of heredity. 
Progressive muscular atrophy has also been observed to develop 
after typhoid fever, diphtheria, rheumatic fever, and other acute 
affections. 

Diagnosis. To guard against diagnostic errors it is important to 
keep in view the peculiar clinical history of progressive muscular 
atrophy. It is a bilateral disease, and produces singular deformities 
of the trunk and limbs, resulting from the disappearance of entire 
muscles or parts of muscles. Muscular wasting is not an uncommon 
symptom in a number of spinal affections, but its mode of develop- 
ment deviates from that of the progressive type. 



SYSTEMIC DISEASES OF THE SPINAL CORD. 101 

In lead palsy affecting both upper extremities there is "wrist 
drop," but no deformity of fingers as in wasting palsy; the extensors 
of the forearm, and not the small muscles of the hand, are atrophied, 
and there is complete loss of the electric excitability in the atrophied 
muscles ; whilst in progressive muscular atrophy, owing to unaffected 
fasciculi of muscular fibres, there is still a response, however faint. 
There is besides a history of exposure to the poisonous influence of 
the metal in lead palsy. 

Prognosis. Cases in which the atrophy shows a tendency to 
become rapidly general give a very unfavorable prognosis. Patients 
may survive for many years if the disease is of a mild character and 
makes frequent pauses in its progress. Implication of the muscles 
of deglutition and respiration directly endangers life. Eecoveries, 
even under the most favorable conditions, are exceptional. 

Treatment. Erb's emphatic declaration that electricity is the 
only remedy we possess against progressive muscular atrophy, 
and Duchenne's prior recommendation to begin the treatment at once 
with strong faradic currents, express the general opinion of the 
inefficacy of any other therapeutical measure in this disease. It is 
now the practice to prefer a descending galvanic current with frequent 
interruptions — the positive pole being applied to the vertebral column 
and the negative pole to the muscles. Duchenne is so strongly 
convinced of the beneficial action of electricity even in advanced cases 
of the disease that he expects decided improvement from energetic 
faradisation so long as the affected muscles respond to the current. 

Pseudo-Hypertrophy of Muscles (Lipomatous Hypertrophy 

of Muscles). 

This is a peculiar type of muscular atrophy in which the wasting 
is replaced by an enormous development of fat, so that the muscles 
appear to be greatly hypertrophied. The gastrocnemii frequently 
present an extraordinary degree of fullness and rotundity, and yet the 
muscular weakness is such that the patient finds great difficulty in 
standing and walking. 

Etiology. Children of a tender age and of the male sex are 
almost exclusively affected by this disease. A hereditary tendency is 
undeniable. 



102 MANUAL OF NEEVOTTS DISEASES. 

Anatomical Changes. The most degenerated muscles appear to be 
composed entirely of fat. A few isolated muscular fibres may be 
found here and there. The less deteriorated muscles consist of 
muscular bundles of normal structure, but separated by interposed 
fat. These muscles are of a soft consistence, and of a pale yellowish 
or reddish color. No morbid alterations are found in the nervous 
system. Pathologists are of the unanimous opinion that the disease 
originates in the muscles; though it is undecided whether the morbid 
process is of the nature of hyperplasia of the interstitial tissue which 
compresses and atrophies the muscular fibres, or whether this change 
results from the excessive deposit of fat. 

Clinical History. As the disease invariably begins in the lower 
extremities, and occurs, in the majority of cases, in early youth, 
parents will inform us that the child was slow in learning to walk, 
that it constantly tripped and fell, and experienced much difficulty 
in mounting stairs. Very marked symptoms are observed as the 
disease progresses. The gait is unsteady and waddling. When 
leaning forward the body doubles up like a jack-knife. The hands 
are pressed against the knees in the effort to regain the erect position. 
In standing or walking there is a peculiar posture of the body which 
the patient instinctively adopts to steady himself. The shoulders 
recede and the abdomen is thrown forward, thus resembling in 
miniature the position of a woman in the last months of pregnancy. 
On witnessing the efforts of the little patient to sustain his balance 
in the acts of standing and walking (in which he but poorly succeeds), 
one is surprised at the enormous volume of the calves of the legs. 
Other muscles of the lower and upper extremities and of the trunk 
are found in a similar condition, but those of the neck and head are 
exempt. It is remarkable that the affected muscles still retain their 
electro-muscular contractility. No other noteworthy symptoms 
are observed throughout the course of the disease. The general 
health continues satisfactory. The disease slowly progresses until 
patients are consigned to their beds for life. 

Treatment. The very few favorable reports concerning the treat- 
ment of this disease come from electro-therapeutists. Nothing need 
be added here to what has already been mentioned on the subject 
of electrical treatment in progressive muscular atrophy. 



CHAPTER X. 
DISEASES OF THE MEMBRANES OF THE BRAIN. 

Pachymeningitis. 

Suppurative inflammation of the external layer of the dura mater is 
a secondary affection, resulting from traumatic lesions and diseases of 
the cranial bones. 

"When the internal layer of the dura mater is the seat of the 
inflammatory process, a fibrous exudation is thrown out, which, on 
becoming organized into a false membrane of great vascularity, gives 
rise to hemorrhages. The hematomatous tumor which is thus formed 
compresses the cortex, causing softening and discoloration of its 
tissue. 

Internal pachymeningitis is, in the majority of instances, also of a 
secondary nature. It arises from injuries and disease of the skull. 
Chronic alcoholism favors its spontaneous development, especially in 
old persons. 

Clinical History. The symptomatology of internal and external 
pachymeningitis is identical with that of simple meningitis ; but 
when the former develops slowly and insidiously it cannot be 
clinically distinguished from intracranial tumor. At any rate, the 
symptoms point then to the existence of serious brain trouble of an 
obscure nature. There is severe headache, mental obtuseness, inco- 
herent speech, feebleness of the limbs, and progressive emaciation. 
These symptoms are subject to remissions and exacerbations, and 
occasionally apoplectic attacks occur. Failure of the mental powers, 
embarrassment of respiration and difficulty of deglutition constitute 
phenomena of the gravest import. Death is sometimes preceded by 
convulsions and coma. 

Simple Meningitis. 

Simple or primary inflammation of the pia mater is not a disease 
of frequent occurrence. Traumatic meningitis is far more common. 
Secondary forms of acute meningitis develop from intracranial 



104 MANUAL OF NERVOUS DISEASES. 

diseases, and occur in the course of different acute affections. Chronic 
meningitis is not easily recognized during life. There is a basilar 
meningitis, the leirto-meningitis infantum, whose etiology is obscure. 

Anatomical Changes. The morbid alterations in simple meningitis 
are, as a general rule, limited to the convexity of the brain. The pia 
mater is greatly injected and infiltrated with pus. Thick yellowish 
pus is also found in the subarachnoid spaces and along the course of 
the meningeal bloodvessels. The arachnoid has an opaque appearance 
and is filled with the purulent exudation. Spots of softening occur in 
the substance of the brain where the inflamed pia is closely adherent 
to the cortex. 

Clinical History. Simple meningitis has few premonitory symptoms. 
There is an initial chill, though it may be absent. The onset usually 
begins with violent headache, febrile excitement, vomiting and nervous 
prostration. From the beginning the disease assumes a serious 
aspect. The patient is restless and irritable ; he shuns the light and 
is annoyed by loud sounds ; the eyes glisten ; the pupils are contracted ; 
the skin is hot and dry; a circumscribed flush is seen upon the 
cheeks; the breathing is hurried, or rather panting; the intelligence 
is impaired ; speech is slow and at times incoherent, and an active 
delirium soon sets in. Oscillation of the eyeballs and strabismus are 
frequently observed. The cutaneous sensibility is much increased. 
Even in a state of apathy the patient evinces the signs of hyper- 
esthesia and of heightened reflex excitability. 

Motor disturbances of an irritative character are witnessed so soon 
as the disease is fully established. They consist of stiffness of the 
muscles of the neck, retraction of the head, twitching of the muscles 
of the upper and lower extremities, and, toward the end, subsultus 
tendinum and tremors. Infants roll the head from side to side or 
bore it into the pillow, and utter piercing cries. General convulsions 
are liable to supervene in these little patients ; sometimes there is 
trismus; the fontanels are distended, the vomiting continues; the 
bowels are constipated and the urine is scant. 

Among all these symptoms during the stage of cerebral excitement 
none is so conspicuous and constant as the headache. The pain 
may be fixed to one spot or be diffused, but patients always complain, 
so long as they are conscious, of its great intensity and unbearable 
character. 

With the increase of the exudation and ventricular effusion, 



DISEASES OF THE MEMBRANES OF THE BRAIN. 105 

somnolence and torpor take the place of the symptoms of cerebral 
irritation. The pupils are now dilated, the pulse is rapid and 
intermittent, the respiration irregular, and the urine is often retained. 
These signs of cerebral compression are frequently followed by 
paralysis of the hemiplegic type, and finally profound coma closes 
the scene. 

Acute meningitis occurring in persons of an advanced age presents 
certain peculiarities. The symptoms are not well marked and 
develop insidiously. There is little or no headache, the fever is 
moderate, but active delirium sets in early and may be quickly 
succeeded by fatal coma. In other cases there is merely mental 
confusion, a vacant expression of the countenance, tremor, much 
restlessness, and a rapid sinking of the vital powers. 

Meningitis is also one of the manifestations of cerebral syphilis. 

Very dangerous cephalic symptoms occasionally light up during an 
attack of inflammatory rheumatism, which may be taken for those of 
meningitis; but post-mortem examination does not confirm this 
supposition. The affection is characterized by a high grade of febrile 
excitement, a busy delirium and restlessness. Headache and vomiting 
are absent. I saw a case answering to this description in a young 
man who had gonorrheal rheumatism. The patient was very 
loquacious and slept but little. He ceased to complain of pain in 
his swollen knee and had no headache. He soon fell into a state of 
coma in which he died. 

Diagnosis. It is a difficult point in differential diagnosis to 
distinguish acute meningitis from acute encephalitis. Practically 
this is of little moment, for inflammation of the pia mater usually 
involves the substance of the brain. 

Delirium tremens is distinguished by the tremor, the characteristic 
hallucinations and the absence of the headache. There is besides 
a previous history of inebriation. 

In typhoid fever the headache is far less intense than in meningitis, 
and there is a typical range in the rise of the temperature. It is 
only in the early stage of typhoid when a doubt can arise. This will 
at once be removed on the occurrence of the diarrhoea, the appearance 
of the roseolar spots, and the tenderness and gurgling in the right 
iliac region. 

Much as the simple and tubercular meningitis have in common, 
there are, nevertheless, points of distinction which will be mentioned 
when the latter disease is discussed. 



106 MANUAL OF NERVOUS DISEASES. 

Prognosis. Acute meningitis is an exceedingly grave disease. 
Very few cases recover. Death may take place within forty-eight 
hours. Generally, however, the fatal termination occurs at the 
end of the first week, though exceptional cases may linger for two 
or three weeks and even longer. Eecoveries do occur, but mental 
impairment is apt to remain, probably from development of chronic 
meningitis. 

Treatment. It is at the onset of simple meningitis that remedial 
measures, promptly carried out, offer any prospect of success. Among 
them, none are held in higher estimation by experienced practitioners 
than bloodletting, brisk purging, and cold applications to the head. 
A vein should be opened in the sitting posture and allowed to 
bleed until signs of faintness make their appearance. The vene- 
section may be repeated if thought advisable, or leeches may be 
applied to the temples or behind the ears to keep up the effects of 
the depletion. An energetic purgative accomplishes the same end. 
To insure prompt action, a full dose of calomel or the compound 
infusion of senna should be given. 

However much prejudice may be felt against the adoption of such 
harsh measures, they are justifiable in a desperate disease like that of 
acute meningitis, for which we have nothing better. 

To derive the greatest amount of benefit from the application of 
cold to the head it is insufficient to use a rag soaked with water. 
A bladder filled with crushed ice to which salt is added is immeasu- 
rably superior. But the ice-helmet answers the purpose still better. 
There is another mode of applying cold to the head which nothing 
else can exceed in its calming and soothing effect. This is accomplished 
by letting a small stream of water fall on the head for a limited time. 
But irrigation is not adapted to children and old persons ; used, 
however, with proper caution, to avoid its too great depressing effect, 
the speedy subsidence of the restlessness and jactitations of the 
patient is astonishing to witness. Before making these applications 
to the head, the hair should be cut. As an adjuvant, woollen cloths 
wrung out of hot water should be wrapped around the lower limbs. 

Blistering is indicated when coma threatens to set in. A cap of 
fly-plaster may be applied to the shaven head, or blisters may be 
drawn on the nape of the neck and behind the ears. At this time, 
purgatives should be discontinued. 

The stage of collapse must be met by stimulants, though they avail 
but little. 



diseases of the membranes of the brain. 107 

Tubercular Meningitis. 

Anatomical Changes. Formerly the term " acute hydrocephalus" 
was applied to a basilar meningitis occurring in childhood. It is now 
ascertained that, in the great majority of cases, the exciting cause 
which sets up the inflammatory process is the development of miliary 
tubercles in the pia mater. The grey granulations are found in 
greatest abundance in the basilar portion of this membrane. They 
can be readily detected when the pia is stripped from the brain. 
Sometimes they are found dotted over the whole surface of the brain 
and between the convolutions. Wherever they occur they invariably 
follow the course of the bloodvessels. The tubercles also appear in 
the form of conglomerated masses of different sizes which are more 
or less degenerated. In this condition they are often found mixed 
with the inflammatory exudation. In other respects the anatomical 
changes distinctive of tubercular meningitis are of an analogous 
character with those of the simple variety. A copious effusion is 
usually found in the ventricles. In general tuberculosis many of the 
internal organs show the presence of miliary granulations. They are 
never absent from the lungs. 

Etiology. Tubercular meningitis occurs with the greatest frequency 
between the second and seventh year, though adults are not exempt 
from it. Heredity and unfavorable hygienic influences predispose to 
the development of this disease. From the fact that tubercles- of an 
older date are not infrequently found at post-mortem, it is inferred 
that their presence may be tolerated until, through some exciting 
cause, they light up the meningeal inflammation. It is a matter of 
experience that children, under the debilitating influences of the 
various affections to which their age renders them liable, not 
seldom succumb to tubercular meningitis. 

Clinical History. It is customary to divide the history of tuber- 
cular meningitis into three stages. The first stage includes the 
symptoms of cerebral irritation ; the second stage is marked by the 
effects of compression which the exudation exerts on the brain ; and 
the third stage, or the stage of collapse, refers to the final paralysis 
of important nerve centers. In cases which take a typical course all 
these different phases of the disease are presented in regular 
succession. But the sudden or slow development of the exudation, 
the variable extent of the cerebral lesion, and the degree of mechanical 



108 MANUAL OF NERVOUS DISEASES. 

compression, constitute variable factors that greatly modify the 
symptomatology of the disease in individual cases. 

In the adult the disease may begin suddenly with acute symptoms. 
A severe chill is rapidly followed by a high temperature and the 
signs of cerebral irritation. In small children the disease is 
occasionally ushered in by violent vomiting and general convulsions. 
But in the majority of cases the complete establishment of the 
disease is preceded, for an indefinite period, by groups of symptoms 
which result from the slow progress of the meningeal inflammation. 
These premonitory symptoms are usually not of a character to 
occasion alarm. Far more frequently they will be attributed to 
difficult dentition, gastric derangement, irritation of the bowels, 
or to an ephemeral febrile affection. A child is noticed to emaciate, 
to lose its appetite, and be troubled with irregularity of the bowels. 
The tongue is coated, the thirst increased, there is nausea and 
occasional vomiting. In the evening the temperature rises; the 
pulse is accelerated ; sleep is disturbed by starts and cries, and 
during the daytime the child appears languid and drowsy. An 
older child shows irritability of temper; complains of headache; 
frequently abandons its playthings and sleeps at unusual hours. 
Infants at the breast are apt to chew the nipples, to suck with great 
avidity for a little while and then to suddenly let go their hold. 
The milk is often regurgitated immediately after nursing. They 
either, doze continually or cry incessantly. Sometimes they are 
subject to convulsions of brief duration. Many of these phenomena 
disappear for a short period ; but the improvement is delusive. The 
established disease is characterized by symptoms which unmistakably 
indicate an acute cerebral affection. 

Headache stands first in the rank among the initial symptoms. It 
persists with slight abatement so long as the patient is at all conscious. 
The pain is felt most intensely in front. The facial expression bears 
witness to its severity. Some patients break out in loud lamentations, 
grasp the head tightly with their hands or bury the face deeply into 
the pillow. I saw a little girl beating her forehead with her fists, 
from which she would not desist for days. 

The cephalalgia is attended, in many instances, by vertigo. This 
swimming of the head is aggravated when the patient rises. 

Vomiting is also one of the most constant symptoms at the 
outset, at least in children who have not vomited before. 

Obstinate constipation of the bowels is the rule, though I have 



DISEASES OF THE MEMBRANES OF THE BRAIN. 109 

repeatedly observed cases during the summer months ushered in by 
a profuse diarrhoea which simulated an attack of cholera infantum. 
At this stage a morbid sensitiveness to light and sound and cutaneous 
hyperesthesia constitute well-marked symptoms. Contraction of the 
pupils is rather common. The pulse is moderate, especially in the 
adult. It is sometimes but 60 beats to the minute. In children the 
pulse is rapid, wiry and frequently intermittent. The range of the 
temperature runs parallel with the pulse. The respiration in infants 
is hurried, interrupted and sighing. There is a tendency to 
somnolence. Older children are wakeful and restless. At the onset 
and for the following few days there is little psychical disturbance ; 
but as the disease progresses, an apathetic condition is observed 
in grown persons. The intelligence becomes obtuse, the speech 
hesitating, and the patient dislikes to answer questions. In individual 
cases a very active delirium develops. Patients constantly throw off 
the bedding, jump out of bed and attempt to leave the room. The 
duration of the first stage averages about eight days. 

Certain prominent symptoms now make their appearance 
significant of the stage of compression. It is highly probable that 
the sudden slowing of the pulse in the adult, and the dilatation of 
the pupils at this stage, result from ventricular effusion. The 
tendency of the child to bore the occiput into the pillow, the 
retraction of the head, or opisthotonos, indicate basilar exudation. At 
this time the vomiting ceases and does not return. The face, finger 
and toe-nails become cyanotic, the features are pinched, the eyelids 
half closed and the eyeballs fixed and turned upward. Strabismus 
is usually an earlier symptom. At intervals the hydrocephalic cry 
is heard, although the somnolence increases. Ophthalmoscopic 
examination of the fundus of the eye frequently detects miliary 
tubercles of the choroid, and neuro-retinitis. The "tache cerebral " 
is sometimes well marked. Deglutition begins to be performed with 
difficulty. The respiration is sometimes remarkably slow or irregular. 
A very characteristic symptom is the sunken (boat shape) appearance 
of the abdominal walls. Slight spasmodic movements of the limbs 
and of the facial muscles, or repeated attacks of general convulsions 
in small children, are not seldom present at this period. Facial 
paralysis and ptosis may also occur. In infants, very curious move- 
ments of an automatic character are occasionally witnessed, such as 
a rhythmical waving of the arm across the face, or a steady pressure 
of the back of the hand on the eye. The duration of this stage 



110 MANUAL OF NERVOUS DISEASES. 

varies; in the greater number of cases it is about a week. Individual 
cases occur in which there is no period of transition between the first 
and third stages. Occasionally some of the grave symptoms disappear 
for a few days ; but the improvement is deceptive. 

The third and final stage is marked by symptoms of general 
paralysis. Swallowing of food is now impossible; the reflexes are 
abolished ; the evacuations pass away involuntarily ; the abdomen is 
tympanitic ; the skin is cold, and covered with a clammy sweat ; the 
pulse is exceedingly rapid and thready ; the coma profound ; 
convulsions repeatedly occur, and, under these symptoms of utter 
collapse, death takes place within twenty-four or forty-eight hours. 

Diagnosis. There are few acute diseases of infancy that offer 
greater difficulties to diagnosis than the prodromic period of 
tubercular meningitis. A decisive judgment in respect to the nature 
of the symptoms will often be held in suspense until it becomes 
clear that they neither mean the cutting of a tooth nor intestinal 
irritation caused by worms, nor gastric trouble, nor any other trifling 
cause. Under all circumstances it is advisable to inquire carefully 
into the history of the patient; There are families who lose their 
children, when of a certain age, as they say, from " brain fever." An 
obstinate cough or the evidences of scrofulosis point to the probable 
existence of the tuberculous diathesis. 

The distinction from simple meningitis chiefly refers to the 
following points: Simple meningitis develops suddenly; the 
headache is intense; the delirium active; convulsions occur early, 
often at the onset, and the disease runs a short course. Tubercular 
meningitis develops slowly; the headache and delirium are not 
prominent symptoms ; convulsions, as a rule, come on at a late period, 
and the duration of the disease occupies from two to three and 
sometimes four weeks. 

Tubercular meningitis may be confounded with typhoid fever, 
especially as the premonitory symptoms of these diseases bear a 
close resemblance to each other. But typhoid fever can easily be 
distinguished by the gradual rise of the fever temperature, the 
diarrhoea, the rash, the iliac tenderness and the state of the tongue. 
At no time does typhoid fever present those evidences of brain 
compression which constitute such marked features of meningitis. 

Prognosis. The few reported cases of recovery from tubercular 
meningitis testify to the gravity of its prognosis. Eelapses occur 



DISEASES OF THE MEMBRANES OF THE BRAIN. Ill 

even in such exceptional cases, or idiocy and epilepsy remain for 
life. The fatal termination directly results from compression of vital 
nerve centers. 

Treatment. From all sides the appeal is made to the family 
physician to put into practice the well-known prophylactic measures 
which tend to prevent the development of tuberculosis, since 
therapeutics fails to successfully grapple with this disease when 
once established. An infant with a hereditary predisposition to 
tuberculosis or scrofula should certainly be provided with a healthy 
nurse. Or, in case parents cannot afford to incur such an additional 
expense, it is even preferable to feed the child with diluted cow's 
milk. Superabundance of clothing and hot rooms should be avoided, 
as both have an enervating effect on the child. The opposite extreme 
of the so-called "hardening process " is just as reprehensible. Cool 
bathing and country air constitute a far more rational method of 
invigorating the system. Children should sleep in large, dry rooms 
that can be easily ventilated. A generous but a not too stimulating 
diet must be allowed. 

The employment of an energetic treatment in this disease is 
obviously objectionable. Local abstraction of blood from the head 
gives only temporary relief to the cephalic symptoms. The applica- 
tion of cold to the head and an active purgative answer the same 
purpose. Iodide of potassium is a remedy which should not be 
withheld. Eevulsives are indicated in coma, but little children 
should not be blistered. 

Inflammation of the Sinuses of the Dura Mater. 

This is a secondary affection. It occurs under circumstances 
which set up an adhesive or suppurative phlebitis that leads to 
thrombosis of the affected sinus. The extension of the inflammation 
from otitis media to the temporal bone may have a similar result. 
The variability of the symptoms renders it frequently impossible to 
recognize the true nature of the disease. It begins with signs of 
cerebral irritation characteristic of acute meningitis, and finally 
takes on the appearance either of a low typhoid condition or of 
pysemia. 



CHAPTER XL 
DISEASES OF THE BRAIN. 

Cerebral Htperaemia (Congestion of the Brain). 

Increased flow of arterial blood to the brain is not a frequent 
pathological condition, and therefore its diagnosis should not be 
lightly made. It must be carefully distinguished from venous 
congestion of the encephalon. The former implies an active determin- 
ation of blood to the head, such as results from opium, camphor, 
vinous stimulants, a full meal, simple hypertrophy of the heart, and 
the pyrexia of intermittent fever. 

The distress caused by active cerebral hyperemia is sometimes 
great. There is pain of the head, dizziness, throbbing of the temporal 
arteries, a flushed tumid face, and suffusion of the eyes. These 
symptoms occasionally pass into delirium. Persons of an excitable 
brain are very liable to suffer from this " rush of blood to the head." 
It is probably, also, induced by the direct influence of the rays of the 
sun to the head, though it must be remembered that "sun stroke" 
usually depends upon the depressing effect of immoderate heat. 

Cerebral hyperemia in early childhood simulates the leading 
symptoms of meningitis. It is attended by febrile excitement, rest- 
lessness or drowsiness and other cephalic disturbances. This condition 
can be traced to some palpable cause, usually to difficult dentition, the 
influence of cold, gastric or intestinal disorder, &c, and readily 
yields to the appropriate treatment. 

Passive congestion of the brain is a secondary affection, invariably 
resulting from an impediment to the return of blood from the brain. 
This occurs in cardiac and pulmonary diseases which obstruct the 
venous circulation. The face in well-marked cases has a purplish 
tinge. The symptoms of cerebral excitement are due to a badly 
nourished and overburdened brain. 

Cases are sometimes met with resembling " strokes of apoplexy," 
which may or may not be ushered in by convulsive seizures or active 
delirium ; they occasionally prove fatal, and yet the autopsy only 



DISEASES OF THE BRAIN. 113 

reveals an abnormal fullness of the venous bloodvessels, which can 
hardly be considered an adequate cause of death. It is held to be 
permissible to give the diagnosis of " congestive apoplexy," before a 
coroner's jury, in cases of this kind. Trousseau was of the opinion 
that these so-called instances of congestive apoplexy are of an 
epileptic nature. 

Treatment. Venesection used to be the indiscriminate practice in 
cerebral hyperemia. The free abstraction of blood may be service- 
able in young, robust persons of a florid complexion, who suffer from 
intense headache, violent action of the heart, and oppressed respiration. 
I have even seen prompt relief from general bleeding in patients 
complaining of cephalic symptoms due to hypertrophy of the heart, 
which no other kind of treatment would ameliorate. Such an active 
measure is, however, seldom required in cerebral congestion. Leeches 
to the head and brisk purgation suffice in the majority of cases. A 
course of aperient medicines is often of great benefit, when there is 
a tendency to determination of blood to the head. Alcoholic stimu- 
lants and strong coffee must be interdicted. An opposite plan of 
treatment is indicated in old persons, whose symptoms of cerebral 
hyperemia generally result from weakness of the heart's action. 
This class of patients is benefited by brandy or rum punch. 

The treatment in small children must be guided by considerations of 
their tender age and constitution. It is above all things important 
to keep in view the numerous exciting causes, however trifling, which 
in these little patients are exceedingly apt to induce functional 
disturbance of the brain. 

Cerebral Anemia. 

Experimental researches tend to confirm the symptomatology 
which is thought to characterize cerebral anaemia. Compression of 
the carotids in the human subject causes pallor of the face, loss of 
consciousness, dilatation of the pupils, slow and sighing respiration, 
and sometimes vomiting and general convulsions. The sudden 
development of cerebral anaemia is witnessed in profuse hemorrhages, 
failure of the heart's action and during profound mental impressions ; 
its gradual establishment results from chlorosis, prolonged lactation, 
and all chronic affections that impoverish the blood. 

The brain and the membranes in cerebral anaemia present a pale 
appearance, which is particularly noticeable in the cortical substance. 



114 MANUAL OF NERVOUS DISEASES. 

Few or no puncta vasculosa are visible on section. There is usually 
an increase of the serous fluid in the ventricles and subarachnoid 



Olinical History, Cerebral anaemia, in its extreme aspect, is 
witnessed in sudden loss of large quantities of blood. There is a 
deadly pallor of the face, the eyes are sunken, the sight becomes 
dim, the respiration is slow and sighing, the pulse feeble and 
thready; there is a disposition to drowsiness, and vomiting not 
seldom occurs. 

The fainting fits resulting from powerful mental impressions, or 
rather emotional shocks, are examples of what may be called acute 
cerebral anaemia. Of a similar nature is the syncopal attack of the 
medical student who for the first time witnesses a bloody operation 
in the surgical clinic. The semi-unconsciousness, the clenched 
hands and twitchings of the facial muscles may be mistaken for the 
symptoms of an epileptic fit. Suddenly elevating the head of a 
patient in the early convalescence from typhoid fever may be followed 
by a fatal result from cerebral anaemia. 

The slow development of cerebral anaemia is attended by headache 
and drowsiness; mental and physical efforts become irksome and 
distasteful, and the temper is irritable. Incomplete respiration 
causes frequent gaping. The appetite is indifferent, and sometimes 
nausea and vomiting supervene. Hallucinations of sight and hearing- 
are not uncommon in severe cases, especially in females. 

The " hydrocephaloid " of Marshall Hall is a form of cerebral 
anaemia which appears in small children during the course of 
exhausting diseases, especially cholera infantum. There is a stage of 
excitement in which the head is hot, the face flushed, the pulse 
rapid, the sleep disturbed, and the general sensibility much increased. 
This is succeeded by signs of depression, pallor, and coldness of the 
surface of the body, a small pulse, slow respiration, and sluggishness 
of the pupils. The child lies quietly on its back in a sort of stupor 
with the eyelids partly closed. The symptoms apparently point to 
the existence of serious brain trouble; but if the true state of the 
case be promptly recognized, they usually yield to appropriate 
treatment. 

Treatment, Ordinary fainting fits quickly subside if the patient 
be placed in a recumbent position and cold water dashed into the face 
to excite reflex acts of respiration. In cases of unusual severity the 



DISEASES OF THE BRAIN. 115 

head should be lowered and the feet elevated. Ether and camphor, 
aromatic spirit of ammonia, or brandy, should be repeatedly given, 
The hypodermic injection of ether has a more prompt effect. 

Hydrocephaloid, during the stage of cerebral excitement, demands 
the cautious application of cold to the head, which must at once be 
abandoned when symptoms of depression make their appearance. 
The latter require a supporting and tonic treatment. Milk-punch 
forms an excellent article of diet in these cases. 

The treatment of the anaemic condition of the brain, when it 
depends on general anaemia, is obvious enough. Sufficient rest, fresh 
air, and a generous diet are indispensable. The reputed tonics, iron, 
quinia, and cod liver oil do excellent service. To improve the 
digestive functions it is advisable to order pepsin, pancreatin or malt 
extract. The stomach should not at once be overwhelmed by full 
meals and large doses of medicine. 

Cerebeal Hemorrhage. 

Apoplexy. The apoplectic condition occurs under a variety of 
circumstances. Its principal phenomena embrace loss of conscious- 
ness and insensibility. In addition other symptoms of minor 
importance are frequently witnessed which relate to the state of the 
pupils and alterations of the pulse, respiration and temperature. 
When this combination of symptoms is accompanied or followed by 
paralysis, it is popularly named " a stroke of apoplexy." The great 
majority of cases of apoplexy is the result of extravasation of blood 
into different parts of the brain. It is, therefore, proper to adopt the 
more precise nomenclature of " cerebral hemorrhage." 

Etiology. The chief factor concerned in rupture of a cerebral 
bloodvessel and consequent effusion of blood into the substance of 
the brain, is a diseased condition of the small arteries. Degenerative 
changes of a sclerosed or atheromatous character cause thinning 
and bulging of the vascular walls, which lead to the formation 
of circumscribed dilations of the arterial coats. These ' miliary 
aneurisms,' as they are called, vary in size from a millet seed to a 
pin's head, and occur isolated or in large numbers. Their brittle 
condition renders them liable to rupture, which is favored by any 
cause that increases the blood pressure. 

The greatest mortality from cerebral hemorrhage occurs in 
advanced life. The disease is more common in the male than in the 
female sex. 



116 MANUAL OF NERVOUS DISEASES. 

Anatomical Changes. With rare exceptions only one side of the 
brain is the seat of the hemorrhage. The extravasated blood tears 
up the brain tissue and forms a clot. Occasionally the effused blood 
bursts into a ventricle or escapes to the surface of the brain. As a 
rule, only one clot occupies the brain, but two and even three recent 
clots, or a clot of an older date, may be found on post mortem 
examination. Clots are of various sizes. They may not exceed the 
size of a pea or be as large as a man's fist. Very large extravasations 
flatten the convolutions and thereby increase the volume of the 
affected hemisphere. 

A recent clot presents the appearance of a dark, pitchy mass, which 
is composed of the effused blood and the debris of the destroyed 
brain tissue. The contiguous substance of the brain is infiltrated 
with the blood and is softened. The edges of the cavity in which 
the clot lodges are jagged and irregular. 

The clot itself undergoes certain changes. It assumes a brownish 
or saffron tint and gradually becomes absorbed. New connective 
tissue, which develops around the clot, organizes and forms a cyst. 
This cyst is frequently found to contain an ochre-colored fluid, and 
sometimes in old standing cases it is replaced by cicatrical tissue of 
a rusty color. 

Clinical History ; Premonitory Symptoms. A person is said to be 
threatened with apoplexy when certain symptoms or "warnings" 
make their appearance. These so-called premonitory symptoms are 
identical in character with those which are ascribed to cerebral 
hyperemia, to which the reader is referred. But it is a matter of 
common experience that in numerous instances of apoplexy from 
cerebral hemorrhage none of these alleged prodromic signs are 
noticed. Greater significance must be attached, in estimating the 
liability to cerebral hemorrhage, to the existence of heart or kidney 
trouble. 

The Apoplectic Seizure. A very copious extravasation, especially 
when the blood is poured out suddenly or breaks into a ventricle, or 
if the rupture happens in the pons, the cerebellum or the medulla 
oblongata, is immediately followed by profound coma, and the 
patient falls down as if struck by lightning. But this is not the 
usual mode of onset. Cerebral apoplexy is far more frequently 
ushered in by headache, vertigo, confusion of thought, sickness of 
stomach and a sensation of faintness. When the seizure comes on 



DISEASES OF THE BBAIN. 117 

during sleep, which is of common occurrence, the patient, on waking 
up in the morning, finds himself paralyzed. There are many cases of 
cerebral hemorrhage in which the apoplectic condition is absent, or 
is of such a slight character as to attract little notice. Hemiparesis 
may be the first and only sign of a clot in the brain. Sometimes 
immediately before the seizure sets in, the mind wanders, speech is 
incoherent, or nausea and vomiting take place, or an arm or a leg 
becomes slightly paralyzed. Now and then general convulsions 
precede an attack. 

The Accessory Symptoms. Stertor a] ways indicates implication of 
the center of respiration, but it is not a constant symptom of cerebral 
apoplexy. The pulse, the temperature, and the state of the pupils 
may be perfectly normal throughout the attack, or they may show 
alterations. All of these subordinate symptoms are more of a 
prognostic than diagnostic value. 

Termination of the Apoplectic Condition. In the greater number of 
cases of cerebral apoplexy, the consciousness is restored after a shorter 
or longer time, hardly exceeding three hours at the utmost. Occasion- 
ally the comatose condition merely amounts to a brief fainting fit. 
Death is imminent if the unconsciousness be protracted beyond 
forty-eight hours. A fatal termination of cerebral apoplexy is 
seldom witnessed in less than fifteen to thirty minutes from the time 
of the beginning of the coma. 

Inflammatory Reaction. If the patient in the course of a few days 
again falls into a stupor and becomes feverish, restless and delirious, 
it must be inferred that an inflammatory reaction has involved the 
brain tissue in the immediate neighborhood of the clot ; these 
symptoms, however, are moderate and disappear quickly. 

The Paralysis. As soon as the patient has rallied from the 
immediate effects of the hemorrhage, i. e. when the apoplectic 
condition has passed off, the evidence of the permanent mischief done 
to the brain becomes manifest. This consists of paralysis affecting 
the side of the body opposite to that of the lesion in the brain. The 
hemiplegia involves the muscles of one half of the face and the arm 
and leg of the same side. The intensity of the paralysis varies from 
slight muscular weakness to absolute loss of motion. 

Ancesthesia. The cutaneous sensibility of the paralyzed side 
remains, as a rule, intact, but the anaesthesia in exceptional cases is 
sometimes well-marked and persistent. 



118 MANUAL OF NERVOUS DISEASES. 

Course of the Paralysis. With the advent of the paralysis the 
chronic stage of cerebral hemorrhage may be said to have commenced. 
Spontaneous improvement of motility up to a certain point is the 
usual course, and even complete restoration of the muscular power 
may eventually take place. But such a fortunate termination is 
rarely witnessed. The facial paralysis in most cases is limited to the 
muscles of the lower part of the face, and often disappears at an 
early date. Improvement of the paralysis of the limbs is first 
noticeable in the leg. Many patients are again able to walk long 
before they have much use of the arm. Sometimes one of the limbs 
or both become stiff soon after the attack. This " early rigidity " is 
of short duration. Contractures of the extremities which develop 
at a late period remain permanent. The intelligence and memory 
deteriorate when the extravasation has been large. There is no 
diminution or alteration of the electric excitability of the paralyzed 
muscles, at least for a considerable period. The faradic muscular 
contractility in old cases is not seldom diminished. 

Localization of the Hemorrhage ; Corpus Striatum. Hemiplegia is 
typical of lesions of the striated body. In fact, this motor ganglion, 
including the lenticular nucleus, is the most frequent seat of cerebral 
hemorrhage. 

Thalamus Opticus. This central ganglion is often implicated in 
hemorrhage of the corpus striatum. It is doubtful whether a lesion 
exclusively confined to the thalamus induces paralysis. 

Pons Varolii. Profuse hemorrhage into this organ proves speedily 
fatal. Profound coma at once sets in, or death is immediately 
preceded by epileptiform convulsions. The " pin's head " contraction 
of the pupils is frequently so well marked in effusions into the pons, 
4hat this symptom may give rise to suspicion of opium poisoning. 
Clots in the pons, according to their size and position, cause different 
forms of paralysis: 1. Hemiplegia of the ordinary type, affecting 
the extremities and the face on the side opposite to the lesion. 

2. Alternate paralysis; the extremities on the side opposite to the 
clot and the face on the same side of the clot being paralyzed. 

3. In rare instances the paralysis is limited to the hypoglossal or 
facial nerve. 

Cerebral Peduncles. Injury to these bodies usually occurs in 
connection with hemorrhage of neighboring parts. The characteristic 



DISEASES OF THE BRAIN. 119 

feature of circumscribed lesion of one of the crura is total paralysis 
of the extremities on the opposite side, and paralysis of the motor 
oculi nerve on the side of the lesion (a cross-alternate paralysis). 

Medulla Oblongata. Hemorrhage affecting this important part of 
the brain rarely occurs. It usually causes instantaneous death. 

Lateral Ventricles. Speedy death, preceded by deep coma, is the 
uniform result of extravasation into these cavities. It may happen 
when the blood comes from the striated body, or the thalamus 
opticus, that the patient emerges for a short period from the apoplectic 
condition, but as the ventricle fills with blood the coma returns with 
fatal result. 

Cerebellum. Hemiplegia associated with the symptoms of 
incoordinate or " forced " movements, deviation of the eyes and 
vomiting, suggests hemorrhage of the cerebellum. 

Cerebral Lobes. Hemorrhage occurring in the medullary substance 
of the cerebral lobes may or may not produce symptoms. Hemiplegia 
of the ordinary type sometimes results from such a lesion. The 
paralysis is attended by psychical disturbances if the cortex is 
implicated. 

Diagnosis. The differential diagnosis between cerebral hemorrhage 
and softening of the brain will be discussed in connection with 
thrombosis and embolism of cerebral arteries. 

Apoplexy followed by paralysis offers the least difficulty to 
diagnosis, for whatever may have been the mode of onset, if paralysis 
of the hemiplegic order exists, there must be some brain lesion. 
But in cases of rapid death in the apoplectic condition — say in the 
course of half an hour, or even less time, the recognition of the true 
state of affairs is not so easy. Cerebral hemorrhage, as a rule, does not 
kill in such a short time. It is far more likely that the fatal result 
depended either on meningeal hemorrhage, the rupture of an aneurism, 
or failure of the heart's action from valvular disease or fatty 
degeneration of this organ. 

The most embarrassing cases, however, are those in which persons 
are found in a state of coma resembling cerebral apoplexy, of whose 
previous history nothing is known. Suppose a man, deeply comatose, 
is picked up in the street by a policeman, or a stranger at a hotel is 
found in a stupor from which he cannot be roused, it would be 
hazardous to express an opinion concerning the true condition of 



120 MANUAL OF NERVOUS DISEASES. 

these patients. If such persons are advanced in years, if the superficial 
arteries are tortuous and rigid, or the signs of renal or cardiac 
disease can be made out, then there is great probability that the loss 
of consciousness is either the effect of cerebral hemorrhage or of acute 
softening of the brain. Still, this does not exclude the possibility of 
injury to the head, deep intoxication, opium poisoning, uraemia or 
epileptic stupor. Generally a due consideration of all the diagnostic 
points in reference to these several morbid conditions will remove 
the doubt, through it is best to be guarded in expressing a hasty 
judgment. It has often happened that the extreme prostration 
presented by a drunken man has induced compassionate people to 
ply him with brandy, and contrariwise a man with a clot in his 
brain has sometimes been arrested by the police on the charge of 
drunkenness. 

Prognosis. Whether a patient who is down with apoplexy will 
come out of it or not depends upon the mildness or gravity of 
the symptoms, or rather upon the quantity and localization of 
the extravasated blood. If the coma be not profound and the 
insensibility incomplete, if there is little or no stertor and the 
pulse and temperature keep within normal limits, the patient will 
in all probability come out of his apoplexy. The case is unpromising 
if the coma is deep and persistent, if there is marked stertor, slow 
and shallow breathing, a retarded or irregular pulse and sinking of 
the body temperature. The chances whether a person who safely 
got over an attack of cerebral apoplexy will have another one are 
much against him if his arteries are diseased or his heart or kidneys 
are affected. 

Treatment. The routine practice of venesection in every case of 
cerebral apoplexy is now generally abandoned, and for good reasons. 
Numerous patients promptly recover from apoplexy for whom nothing 
is done in the way of treatment. It is hardly reasonable to suppose 
that a few ounces of blood, more or less, in the general system can 
exercise any influence in arresting the extravasation from a ruptured 
bloodvessel. The use of derivatives and cold applications to the 
head for the same purpose rests upon equally irrational grounds. 
There are, nevertheless, exceptional cases in which benefit may be 
expected from bloodletting, though it requires much tact and 
judgment to recognize them. The following symptoms are said to 
indicate abstraction of blood : a cyanotic appearance of the face, a 



DISEASES OF THE BRAIN". 121 

hot head, suffused eyes, a vigorous pulse and a labored respiration. 
Even under these circumstances, especially in old people, it is advis- 
able to be contented with the effects of a few drops of croton oil 
placed on the tongue, or stimulant enemata. 

An opposite plan of treatment is indicated when there is pallor 
of the face, the temperature low, the pulse feeble and irregular, 
the respiration slow and shallow, and the pupils widely dilated. 
Patients in this condition are in danger of sinking rapidly. Wine, 
brandy, ether, musk and camphor must be steadily given in large 
doses to prevent fatal collapse. Should a patient be unable to 
swallow, it is necessary to administer the ether or whiskey with the 
hypodermic syringe. The failing respiration may be excited by 
dashing cold water on the face and the bare chest ; the skin should 
be briskly rubbed and sinapisms be applied to the insides of the arms 
and legs. 

It is sufficient, in ordinary cases of cerebral apoplexy, to place the 
patient in a comfortable position, to raise the head and shoulders, 
and to keep off all disturbances. 

The ice-bag must be applied to the head and an active purgative 
ordered, if the inflammatory reaction runs high. Pain in the head is 
frequently relieved by a blister on the nape of the neck. 

Formerly a great variety of remedies were employed with the object 
of promoting the absorption of the extravasated blood. At the 
present day the futility of meddling with the clot is well understood. 
Confidence in the recuperative powers of nature to restore, in some 
measure, the damage which has been inflicted on the brain, is fully 
justified by the improvement of the paralysis which gradually 
goes on. 

Much can be done to prevent or retard a renewal of the hemor- 
rhage by measures which invigorate the general system. Patients 
should be advised to abstain from physical strains and mental 
overwork. 

Infantile hemiplegia results from hemorrhage, embolism, tumor, 
or from menin go-en cephalitis of the cortical motor zone. The 
paralysis sometimes develops during the convalescence from diph- 
theria, typhoid fever, scarlatina and other acute febrile diseases. 
Prom the hemiplegia in the adult it is distinguished by the arrest of 
growth of the bones, especially of the upper extremity. Orthopedic 
measures, assisted by the use of electricity, must be employed to 
prevent atrophy and deformity of the paralyzed limbs. 



122 manual of nervous diseases. 

Softening of the Beain. Cerebral Embolism and 
Thrombosis. 

Since Virchow's important investigations on embolism and throm- 
bosis, it is now generally conceded that softening of the brain, in the 
majority of cases, is due to occlusion of small cerebral arteries. 
Thrombosis of cerebral arteries develops in the same manner as it 
does in other arteries. It either starts from an inflammatory process, 
or a degenerative change which affects the vascular walls and finally 
obstructs their lumen. The emboli which plug up cerebral arteries 
are generally derived from warty excrescences, or so-called fibrous 
vegetations, that form on the valves of the heart after attacks of 
endocarditis. Another source of these emboli is contributed by 
concretions of the internal lining of the heart and the aorta. They 
consist much less frequently of detached particles of cancerous, 
tubercular, or puriform matter. Minute portions from a broken up 
thrombus in the brain may likewise give rise to cerebral embolism. 

The middle cerebral artery being the direct continuation of the 
internal carotid is particularly liable to embolic obstructions, and, as 
its branches do not freely anastomose with arteries from other sources, 
the collateral circulation fails to be established when they are plugged. 
Hence the central ganglia and adjacent parts of the brain which are 
nourished by these " terminal branches" are predisposed to softening. 
The reason why cerebral embolism occurs more frequently in young 
persons than in the old, is owing to the circumstance that the former 
are prone to suffer from rheumatic endocarditis and its consequences. 

Anatomical Changes. The first effect of cerebral embolism is 
anaemia of that limited area of the brain which is cut off from the 
supply of arterial blood. Sometimes the affected brain tissue breaks 
down at once and softens ; but this may be preceded by stagnation 
of the blood in the veins and capillaries. Examined by the microscope, 
it is found that the altered brain substance has undergone destructive 
changes. Its nerve elements have degenerated and appear surrounded 
by an abundance of compound granule corpuscles. The diseased 
brain tissue is finally transformed into a semi-fluid mass, consisting of 
disintegrated nerve cells and fibres. 

Clinical History. An apoplectiform attack is sometimes the first 
intimation of the occurrence of cerebral embolism in persons whose 
general state of health had heretofore appeared to be satisfactory. 
The loss of consciousness is then as complete and comes on as suddenly 



DISEASES OF THE BRAIN. 123 

as in the case of cerebral hemorrhage. Acute softening of the brain 
is, however, more commonly ushered in by convulsions, delirium or 
sickness of stomach. On close inquiry it will often be found that 
patients had previously presented evidences of failing health. 
Usually they are men advanced in life or who had shown signs 
of premature senile decay. Symptoms of deterioration of the 
mental and physical powers may have been noticed for weeks or months 
before the final break-down. Many of these symptoms have the 
character of " warnings," though it is perhaps more correct to consider 
them part and parcel of the attack itself. Thus there is more or less 
headache, vertigo and faintness, unsteadiness of gait, a tendency of 
the body to lean to one side, sensations of numbness and formication 
in the limbs, incoherence of speech, misplacement of words and a 
feeble memory. 

The coma is usually less profound than it is observed in the cerebral 
apoplexy from hemorrhage. Patients can often be roused for a short 
time and they may even answer questions, but soon fall back again 
into the former dazed condition. 

The paralysis is always of the hemiplegic type, and on the side 
opposite to the lesion in the brain. It may be as complete as in 
hemorrhage, but more frequently it is partial. 

Psychical disorder is very common. The alteration may display 
itself by an unwarranted irritability of temper, childish wilfulness, 
outbreaks of unprovoked anger, or a disposition to manifest emotional 
excitement without an evident cause. Patients in this condition are 
easily controlled in their actions by outside influences. They exhibit 
some degree of mental imbecility even when they are at their best. 

Aphasia. This highly interesting phenomenon, which is discussed 
in a former chapter, is often witnessed in occlusion of cerebral arteries. 
In nearly all of the published cases, the softening had involved 
Broca's convolution, or the Island of Eeil and adjacent portions of the 
parietal lobe of the left hemisphere. 

Diagnosis. However difficult and sometimes impossible it may be 
to make the distinction between the clinical history of softening and 
that of hemorrhage, there are certain considerations which serve to 
turn the balance in favor of one or the other. 1. The apoplectic 
condition in softening is frequently not well marked. It may amount 
to no more than a transitory sensation of faintness or confusion of 
mind. Such is seldom the character of the apoplectic attack in 



124 MANUAL OF NERVOUS DISEASES. 

hemorrhage. 2. Mental disturbances, as a rule, are either absent or 
soon pass over in hemorrhage, while in softening they are very 
common and usually persistent. 3. The paralysis in hemorrhage is 
nearly always complete at first, while in softening it is more commonly 
incomplete and partial. 4. A hemiplegia which disappears in a few 
days cannot be due to a clot. It is far more probable that the 
paralysis in the case resulted from an embolus, and passed off as soon 
as the collateral circulation had been completely established. 

Sometimes it is possible to tell whether the softening depends upon 
an embolus or a thrombus. The suddenness of the apoplectic seizure 
speaks in favor of the former, the more so if the patient is a young 
person. 

Prognosis. Although patients frequently recover from the imme- 
diate effects of the occlusion of cerebral arteries, they are liable to 
its recurrence in other parts of the brain. Even if they remain 
exempt from a repetition of attacks, they enter upon the stage of 
chronic softening, which necessarily yields a very bad prognosis. 

Treatment. If it were possible in a case of apoplexy to determine 
with certainty the existence of cerebral embolism, efforts might be 
made by means of tonics and stimulants to restore the circulation. 
But it involves, certainly, a great risk to administer brandy on the 
supposition that an artery has become plugged, whilst it is just as 
probable that hemorrhage is going on. Beyond good nursing and 
paying attention to the secretions hardly anything can be done. The 
restlessness and nocturnal delirium of old paralytics yield more 
readily to small quantities of a generous wine than to anodynes. 
Some benefit may be expected from the syrup of iodide of iron, or the 
syrup of lacto-phosphate of lime and iron. 

Cerebral Tumors. 

A great variety of adventitious growths affect the brain and 
meninges. Their morbid anatomy is identical with similar neoplasms 
that occur in other parts of the body. A brief description of some 
of the more important varieties of brain tumor is, therefore, all that 
is necessary. 

The Glioma is a hyperplastic growth of the connective tissue of the 
brain, variable in size, of a greyish or greyish red color, and sometimes 
extremely vascular, so as to give rise to hemorrhage. It usually 
develops in the medullary substance of the brain. 



DISEASES OF THE BRAIN. 125 

Sarcomatous Tumors indiscriminately invade different regions of 
the brain. They are frequently adherent to the meninges, where 
they give rise to circumscribed inflammation and softening of the 
brain tissue. Sometimes they remain dormant for a long period. 

Tubercle. The favorite seat of tubercle in the brain is the 
cerebellum, and next in frequency, the hemispheres. It occasionally 
attains to the size of a hen's egg. It is more frequently encountered 
in children than in adults. 

Cancer is the most common species of intercranial tumors. The 
malignant growth is usually of the medullary kind. As a rule it is 
a primary cancer and occurs isolated. Multiple carcinomata develop 
in symmetrical parts of the brain. The largest cancerous tumors 
found in the brain start from the orbit and the skull. 

Among the less common forms of cerebral tumors belong aneurism, 
osseous and cystic growths, hydatids and cysticerci. 

Clinical History. It is a singular fact that a cerebral tumor may 
give rise to no symptoms. This latency is probably due to the 
particular seat of the morbid growth or to the absence of changes in 
its composition. 

Headache constitutes the most conspicuous and constant symptom 
of brain tumors. The pain is generally very severe. At first it comes 
on in paroxysms, but later it is continuous. There is no uniform 
relation between the seat of the pain and that of the tumor. When 
the trigeminal nerve becomes implicated it gives rise to a violent 
form of facial neuralgia. 

Vertigo is invariably associated with the headache. This symptom 
is sometimes so aggravated that patients stagger and reel as if they 
were drunk. 

For a considerable period nothing else is complained of but the 
headache and dizziness. By-and-bye new sets of symptoms of great 
significance make their appearance. 

Epileptiform convulsions seldom fail to occur during the course of 
a brain tumor. They cannot be distinguished from true epileptic fits 
if no concomitant symptoms point to the existence of a gross brain 
lesion. The real nature of these convulsive seizures is more readily 
recognized when they are limited to one side of the body, or when 
they are succeeded by paralysis. Slighter motor disturbances of an 
irritative character are observed at an earlier date, consisting of tonic 
or clonic spasms of isolated muscles or groups of muscles. Twitching 



126 MANUAL OF NEKVOUS DISEASES. 

of facial muscles is quite common. The limbs are less frequently 
affected by cramps and stiffness. Choreic movements are occasionally 
witnessed on one side of the body. 

After a longer or shorter period, paralysis or paresis of the 
hemiplegic type supervenes. Paraplegia occurs when the tumor 
involves both hemispheres. Very frequently there is only one-sided 
paralysis of the facial or ocular muscles. 

Disorders of sight are exceedingly common, from slight dimness 
of vision to total blindness. The ophthalmoscope gives important 
information concerning the diseased condition of the optic nerve and 
the retina. The principal changes consist of intra-ocular pressure, 
optic neuritis, and, finally, atrophy of the optic nerve. 

The auditory nerve is frequently implicated, giving rise to defective 
hearing, noises in the ear, or complete deafness. 

Nausea and vomiting constitute occasionally such prominent and 
persistent symptoms as to mask the real nature of the disease. These 
gastric disturbances are nearly always accompanied by headache 
and vertigo. 

A perturbed state of the mind is observed in many cases of brain 
tumor. Maniacal excitement is rare, but hallucinations often exist. 
At a later period somnolence and apathy develop, attended by 
embarrassment of speech, ending in imbecility. At this stage, 
apoplectiform attacks are liable to occur ; the epileptiform paroxysms 
increase in frequency and the paralysis progresses or becomes more 
intense. Finally, the automatic centers of respiration and circulation 
suffer, and fatal coma closes the scene. 

Diagnosis, The indefiniteness of the initial symptoms in many 
cases of cerebral tumor renders diagnosis a difficult task. Even in 
apparently well-marked cases much care is required not to confound 
them with allied brain affections. The differential diagnosis mainly 
turns upon the distinction from cerebral abscess and cerebral 
syphilis. 

Localization of Cerebral Tumors. It is hardly necessary to go over 
the diagnostic points in reference to the localization of brain tumors, 
as this would amount in a great measure to a repetition of what has 
been said respecting the localization of cerebral hemorrhage. 

Neoplasms of the brain, as Hughling Jackson expresses it, 
cause " discharging lesions " and not " destroying lesions." Hence 
the diffused nature of the morbid influence which they exercise 
enhances the difficulty of localizing them. 



DISEASES OF THE BRAIN. 127 

Prognosis. All intracranial tumors, irrespective of their character, 
tend to a fatal termination. Death is sometimes postponed for years, 
and occasionally the symptoms improve, but the pain which no 
treatment can relieve, the loss of sleep, the nausea and vomiting 
exhaust the patient at last, even if the epileptoid and apoplectiform 
attacks do not more speedily bring about the end. 

Treatment. This is entirely symptomatic. Anodynes for the 
relief of the pain are indispensable. The bromides exert some control 
over the convulsive paroxysms. Alcoholic stimulants, tea and coffee 
should be strictly prohibited. Since it is now known that injuries to 
the head may lay the foundation of brain tumors, prophylactic 
measures should not be neglected even in slight injuries. 

Cerebral Abscess. 

Diffuse encephalitis has never been known to occur. In the 
circumscribed softening of the brain, due to embolism, inflammation 
plays no part, but true inflammatory softening is sometimes found in 
the immediate vicinity of a blood clot and tumor. Cerebral inflam- 
mation of a limited extent is recognized by a collection of pus mixed 
with the detritus of the destroyed brain tissue. It is, therefore, more 
proper to speak of cerebral abscess. 

Acute Cerebral Abscesses arise from injuries to the head from 
contusion, as well as from fracture and penetrating wounds of the 
skull. 

Internal otitis is another source of abscess. It usually develops 
suddenly after a patient has suffered for a long time from a running 
ear. The inflammation involves the temporal bone, creeps inward 
toward the cavity of the cranium and sets up a suppurative meningitis. 
In general, it may be said that the symptoms of acute cerebral abscess 
present the characters of traumatic meningitis. 

In persons who are affected with caries or necrosis of the cranial 
or nasal bones there is a tendency to the formation of pysemic abscesses 
within the brain. 

A cerebral abscess may merely present the appearance of a small 
spot of softening. Multiple abscesses are generally small in size. If 
there is only one abscess it is commonly large. The greater part of 
one hemisphere is sometimes transformed into an abscess. 



128 MANUAL OF NERVOUS DISEASES. 

Chronic Cerebral Abscess. A cerebral abscess of old date is 
invariably found encapsulated. The cyst-wall is formed of fibro- 
cellular tissue. Its inner layer is composed of a smooth pyogenic 
membrane. The pus it contains is of a greenish or greenish yellow 
color, of a fetid smell and alkaline reaction. 

The brain substance contiguous to the abscess shows yellow 
softening. 

Clinical History. Pain in the head, first of a remittent and then 
of a continuous character, may be the only sign of the disease for a 
lengthy period. Sometimes the occurrence of an abscess is announced 
by convulsive fits, or one side gradually becomes paralyzed. Kigors 
of a regular intermittent type, or immoderate attacks of vomiting, 
may completely mask the nature of the disease, until the occurrence 
of epileptiform paroxysms, paralysis and coma clear up the case. 
Frequently it can only be said that the patient suffers from some 
serious brain troubles without being able to give a more decided 
opinion. There are cases of cerebral abscess which so greatly 
simulate typhoid fever that the true state of affairs is only revealed 
by the post-mortem appearances. 

Diagnosis and Prognosis. The main reliance in judging of the 
existence or non-existence of cerebral abscess rests on the results of 
a careful examination. In fact, the diagnosis hinges either upon the 
history of some injury to the head, chronic discharge from the ear, 
or a source of pyaemia. Idiopathic cerebral abscess may be fairly 
excluded. A fatal termination appears to be the inevitable result of 
the disease. 

Treatment. Preventive measures are urgently called for in 
affections of the ear and nose that may possibly give rise to cerebral 
abscess. The prime indication in these cases is to give a prompt 
vent to the discharges. Palliative remedies constitute the only 
resource in the established disease. Leeches and cold applications 
to the head in acute, and opium in chronic, abscess prove occasionally 
of benefit. A simple diet and a quiet life may succeed in rendering 
the abscess dormant for an indefinite period. 

Cerebral Syphilis. 

When syphilis involves the substance of the brain, it is after a 
considerable lapse of time subsequent to the primary affection. 



DISEASES OF THE BRAIN. 129 

Usually the implication of the nervous system takes place after the 
outward signs of the constitutional disease have disappeared. 

It is important at the outset to consider the effects of the venereal 
disease on the bones of the skull. The inner table of the cranium 
is subject to syphilitic disease, resulting in caries and necrosis. At 
the base it gives rise to periostitis and exostosis, which compress the 
cranial nerves as they pass out through narrow bony canals. These 
pathological changes favor the development of pachymeningitis and 
basilar meningitis. 

The Syphiloma or gummy tumor constitutes the most frequent and 
important specific lesion within the cranium. As a rule, gummata 
develop in the meninges and more rarely in the bones of the skull. 
Two varieties are recognized, although they are often united. The 
one consists of a soft greyish mass, irregular in shape and blending 
with the surrounding healthy tissue. The other is a firm, cheesy 
substance of a yellowish color, and forms a circumscribed tumor. 
Microscopical examination of the soft syphilitic infiltration shows 
that it is composed of numerous round cells and nuclei, and an 
abundance of bloodvessels. These elements are gathered within 
alveoli and form ill -defined nodules. The dense gummy tumors 
consist of a dry, granular mass resembling caseous matter. 

The favorite situations of these growths are the dura mater and the 
subarachnoid spaces. They seldom originate in the substance of the 
brain, but cause softening of the cortex by the pressure they exert 
on the convexity. Occasionally the optic nerve and the interior 
of the brain are found involved in the specific degeneration and 
atrophy. 

Great importance attaches to the specific changes which the walls 
of the cerebral arteries undergo. The branches of the middle 
cerebral and of the basilar artery are particularly liable to syphilitic 
disease. Their walls become opaque and gradually assume a white 
color, this change being due to a new growth which renders them 
rigid, so that finally they acquire an almost cartilaginous hardness. 
The calibre of the affected bloodvessels is thereby narrowed, and in 
some places becomes occluded by the formation of thrombi and 
emboli. In consequence of this obstruction, limited areas of the 
brain deprived of arterial blood break down and soften. Sometimes 
the brittle condition of an artery causes it to give way under the 
blood pressure, and hemorrhage follows. 



130 MANUAL OF NERVOUS DISEASES. 

Clinical History. Precursory symptoms of variable intensity, and 
little characteristic of a specific causation, frequently make their 
appearance prior to the development of the more grave symptoms of 
cerebral syphilis. They principally comprise headache, dizziness, 
insomnia, vague neuralgic pains, and some impairment of the intelli- 
gence. Not seldom the first intimation that the specific disease has 
involved the nerve -centers is the sudden occurrence of convulsive 
seizures indistinguishable from epileptic paroxysms or some form of 
paralysis. Sometimes an apoplectiform attack or a fit of temporary 
insanity ushers in the involvement of the nervous system. 

Paralysis takes the lead in the frequency of the symptoms that 
attend syphilis of the brain. It assumes a variety of forms. Hemi- 
plegia may either precede or follow an apoplectic seizure. It has 
been observed to occur in one-third of the cases of cerebral syphilis. 
The more unusual forms of paralysis are paraplegia, alternate 
paralysis, paralysis of unsymmetrical muscles, multiple and isolated 
paralysis. The cranial nerves seem to be especially prone to syphilitic 
paralysis. First come the motor oculi. Ptosis has acquired for this 
reason the notoriety of being a sure sign of syphilis. The facial 
nerve comes next in the order of frequency, and the sixth is, perhaps, 
quite as often affected, causing internal strabismus. Isolated paralysis 
of the tongue points to the implication of the hypoglossal nerve. 
Aphasia commonly attends paralysis of the right half of the body. 

A remarkable feature, peculiar to these paralytic disorders, is their 
fragmentary, irregular and changeable character. Sometimes one 
cranial nerve recovers its function, then another is attacked, and even 
the more formidable symptoms of cerebral syphilis disappear 
occasionally with surprising rapidity. In explanation of the simulta- 
neous and successive implication of cranial nerves, it may be fairly 
supposed that the syphilitic exudation at the base of the brain 
involves now one then another or more of the nerve trunks. Since 
it has been ascertained that syphilitic disease of the brain affects the 
vascular walls, there is no great difficulty to account for the singular 
fluctuation of syphilitic brain symptoms, on the supposition that the 
specific alteration retrogrades in one part of the brain and implicates 
in turn another. In the case of the apoplectiform attacks which 
sometimes rapidly pass over without leaving a trace behind, there is 
reason to believe that the effects of embolism wore off as soon as 
the obstructed circulation had been compensated by neighboring 
vascular districts. 



DISEASES OF THE BRAIN. 131 

Sensory disturbances play a subordinate role in cerebral syphilis. 
Violent and constant headache sometimes precedes the more grave 
brain symptoms, but this pain in the head should not be confounded 
with the pain from nodes and periostitis affecting the outside of the 
skull. 

One of the most serious effects of cerebral syphilis is disturbance of 
the visual organs. Sight may be quickly abolished if this result be 
not promptly prevented by appropriate treatment. This complication 
begins with ordinary weakness of the eyes. Total blindness results 
from the development of optic neuritis, which the ophthalmoscope 
readily detects. 

Syphilitic insanity presents no distinctive features. Sometimes all 
the characteristic symptoms of the general paralysis of the insane 
have been observed. 

Diagnosis. The chief dependence in the diagnosis of cerebral 
syphilis must be based on the previous history and present condition 
of the patient. An accurate examination is all the more necessary 
in view of the fact that the invasion of the nervous system usually 
occurs at a late date, when but few or none of the significant marks 
of the constitutional disease are present. Particular regard must be 
had to the order of occurrence of the symptoms, their peculiar 
grouping, the isolated forms and irregular combinations of the 
paralytic disorders. It is rare to encounter the unusual sequence and 
assemblage of symptoms characteristic of cerebral syphilis, in 
ordinary gross lesions of the brain. 

Prognosis. Of all the serious affections of the nervous system, 
those of a syphilitic origin afford the most favorable prognosis, 
especially if the anatomical changes are of recent date, and the 
specific treatment is followed up with promptness and perseverance. 
Permanent and destructive lesions of the nerve centers owing to the 
devastations of the venereal poison, are as little amenable to thera- 
peutics as those of a different nature. Even under these unfavorable 
circumstances some degree of improvement is occasionally attainable. 

Treatment. The only question that can arise in relation to the 
treatment of cerebral syphilis refers to the choice of the specific 
remedies — mercury or potassium iodide. There is a general agreement 
among observers that mercury is preferable when the appearance of 
grave brain symptoms calls for prompt and energetic action. In case 
of irritability of the stomach, it is advisable to resort to the 



132 MANUAL OF NERVOUS DISEASES. 

hypodermic introduction of corrosive sublimate. Mercurial inunction 
for the same purpose is better adapted to hospital than private 
practice. Large doses of the potassium iodide can sometimes be 
given with greater advantage than mercury. 

Labio-Glosso-Pharyngeal Paralysis (Bulbar Paralysis). 

A form of paralysis is now recognized which affects the lips, the 
tongue, the pharynx and larynx, and eventually causes disturbance 
of deglutition and respiration. This complexity of symptoms is 
attributed to a lesion which involves the nuclei of nerves that arise 
from the medulla oblongata. Duchenne, who led the way in pointing 
out the peculiar clinical features of this disease, gave it the 
above name. " Bulbar paralysis " is, however, a more convenient 
designation. 

Anatomical Changes. The roots of cranial nerves situated in the 
floor of the fourth ventricle are found in a state of atrophy. This 
lesion affects, in the order of frequency, the roots of the hypoglossus, 
the spinal accessory, the pneumogastric, the facial and the external 
motor oculi. The roots of the glosso-pharyngeus, the acoustic, and 
trigeminus are seldom involved. Many of the ganglionic cells of 
the degenerated nuclei have disappeared, and those that remain are 
shrivelled and filled with pigment and granular matter. The 
ganglionic cells of the anterior horns, in many parts of the cord, 
participate in the atrophic degeneration. In the majority of cases, 
the neuroglia and bloodvessels in the floor of the fourth ventricle 
are involved in a sclerotic process, which takes an ascending or a 
descending direction, and secondarily affects the nerve elements. 
The paralyzed muscles are of a pale color, infiltrated with fat of soft 
consistence and subject to fibrillary twitchings. They retain their 
electric excitability. 

Etiology. No special cause of the disease is known. It affects 
persons in all classes of society. The greatest number of cases occur 
in the male sex between the ages of forty and seventy years. 
Heredity does not appear to exert a predisposing influence. 

Clinical History. The paralytic symptoms develop insidiously. 
At the begininng of the disease there is merely a slight impediment 
of speech and an oppressive feeling in front of the neck, to which the 
patient pays but little attention. Gradually the heaviness of the 






DISEASES OF THE BKAIN. 133 

tongue increases, and the acts of speaking and eating require unusual 
efforts. It is now observed that certain consonants are pronounced 
in an indistinct manner. By-and-bye the letters R and Sh cease to 
be articulated ; then follow S, L, K, G and T, and later D and N. 
When the lips begin to share in the paralysis, the articulation of the 
vowels and U, and the labials B, P and M, becomes impossible. 
The vowels A and E can be pronounced to the last, though a final 
stage is reached when the miserable patient is only able to emit a 
grunt. 

Immobility of the tongue also interferes with mastication, and for 
the same reason the food cannot be sufficiently carried backward to 
the pharynx. Deglutition becomes, therefore, a difficult task, which 
the patient assists by pushing the food beyond the root of the tongue 
with his fingers. To this is sometimes added a paralytic condition of the 
muscles of the soft palate and the uvula, that allows the regurgitation 
of fluids through the nose or their entrance into the larynx. Other 
muscles supplied by the facial nerve are rarely affected. 

The constant flow of saliva, which trickles over the lips and chin, 
is an annoying symptom resulting from paralysis of the orbicularis 
oris. Patients continually apply the handkerchief to the mouth to 
catch the secretion. The food frequently drops from the mouth, which 
is partly owing to the imperfect closure of the lips, and partly to the 
feeble action of the tongue. 

Implication of the spinal accessory nerve is indicated by disturb- 
ances of phonation. In consequence of defective closure of the 
vocal cords the voice becomes feeble and finally reduced to a whisper. 
During the act of swallowing, morsels of food find their way into the 
open larynx. 

At an advanced period of the disease it is not uncommon to witness 
attacks of dyspnoea and fainting fits. These symptoms show that the 
pneumogastric nerve has become involved. 

In addition to the characteristic symptoms of the disease there are 
a few others which require a brief notice. 

The signs of bulbar paralysis are occasionally preceded by apoplectic 
or epileptic attacks. 

A painful sensation of weight and tension in the nape of the neck 
and occiput is often associated with a similar affection of the tongue. 

Atrophy of the muscles of the neck becomes apparent when the 
disease has reached its height. The movements of the head are 
thereby not only rendered unsteady, but the patient finds much 
difficulty in sustaining it in the erect position. 



134 MANUAL OF NERVOUS DISEASES. 

A most noteworthy feature in the history of labio-glosso-pharyngeal 
paralysis, is the circumstance that few cases of this disease run a 
protracted course without becoming complicated with progressive 
muscular atrophy. But the reverse is quite as common. The reason 
of this frequent association is well expressed by Kussmaul : " Devoid 
of definite limits, the one type passes into another allied one." 

Course and Termination. During the early period of the disease 
there is nothing in the outer appearance of the patient to cause 
anxiety. His general health has not suffered. But a time comes 
when emaciation makes itself apparent, from insufficient supply of 
food, although the appetite is craving. At last the patient presents 
a woeful picture of wretchedness. His helplessness is extreme; 
speech is gone ; the desperate efforts to swallow food are futile ; the 
lips are thinned to a degree of transparency ; the mouth stands open 
and the saliva continually dribbles away. The intelligence remains 
clear, though nothing is left him to convey the sense of his misery 
but the expression of his eyes. 

If some intercurrent disease does not put an end to this pitiable 
condition, death follows from sheer exhaustion; or the escape of 
morsels of food into the air passages brings on a fatal broncho- 
pneumonia. 

Diagnosis. In general, the difficulty of diagnosis in spinal affec- 
tions is due to the complexity of symptoms that blurs their typical 
character. A hasty judgment may declare for the existence of labio- 
glosso-pharyngeal paralysis, although some of its clinical features are 
merely incidental to a disease of a different order. Symptoms of bulbar 
paralysis have been observed in multiple sclerosis, in obliteration 
of some of the basal arteries, and in tumors involving the medulla 
oblongata. But in all such cases the beginning and course of the 
disease differ in many respects from the clinical history peculiar to 
labio-glosso-pharyngeal paralysis. The latter is always distinguished 
by the gradual development of paralysis and atrophy affecting the 
tongue, lips and pharynx, the disturbances of deglutition and speech, 
and a frequent combination with progressive muscular atrophy. It 
would be a serious mistake to confound with bulbar paralysis the 
salivation, the aphonia, the difficulty of swallowing and disturbance 
of speech, suddenly occurring in a hysterical female. 

In regard to prognosis, Trousseau makes the following sad confession : 
" I do not believe that a single case of this disease is on record in 



DISEASES OF THE BRAIN. 135 

which its progress has been arrested even for a few months. From 
one to three years is the usual duration of the disease." 

Treatment. Duchenne and Kussmaul observed temporary improve- 
ment of speech and deglutition from faradization of the palate and 
tongue. Galvanization of the sympathetic is recommended by others. 
The symptomatic treatment has mainly for its object the feeding of 
the patient. This may require the use of the oesophageal tube. 
Attacks of suffocation that endanger life must be relieved by 
tracheotomy. 



\. 



CHAPTER XII. 
THE CLASSICAL NEUROSES. 

Epilepsy. 

The essential symptom of epilepsy consists of a recurrence 
of convulsive seizures attended by loss of consciousness. This 
phenomenon, however striking and formidable looking as it is, would 
not alone vindicate for epilepsy the rank of a substantive disease, as 
spasmodic paroxysms result from a variety of pathological conditions. 
The peculiarity of epilepsy relates to an inexplicable tendency of 
certain nerve centers to be thrown into a state of excitement at 
irregular periods and without an assignable cause, giving rise to a 
typical form of convulsions in individuals who, although they suffered 
from these life-long attacks, nevertheless show no palpable distinctive 
lesion of the nervous system on post-mortem examination. 

Clinical History. Grand Mai. Some epileptics utter a frightful 
scream or yell at the onset of an attack. In the greater proportion 
of cases the patient falls suddenly to the ground without warning 
or making an outcry. The loss of consciousness and of sensibility is 
complete. The limbs become stiff and fixed, the eyeballs deviate to 
one side, the head rotates in the same direction, the face is pallid 
and the features are distorted. Tonic contractions of the chest and 
abdomen quickly supervene which interfere with the act of respiration, 
causing lividity of the countenance. The pupils are dilated and the 
conjunctivae insensitive. This tetanic condition soon changes into 
muscular tremors, followed by clonic spasms that violently jerk the 
head, limbs and trunk. This stage may last from ten to forty 
seconds. 

During the second stage the coma persists and is profound. The 
clonic contractions become general, though occasionally they are 
more marked on one side than on the other. Eespiration is extremely 
embarrassed; the thoracic walls and the diaphragm move convulsively; 
the alao nasi stand widely open ; a gurgling noise proceeds from the 
trachea; mucus collects in the throat and appears as bloody froth at 



THE CLASSICAL NETJKOSES. 137 

the mouth; the tongue is bitten by champing of the jaws; the eyes 
roll in every direction ; the bloated face looks livid or dusky ; the 
veins of the neck are turgid ; the carotids throb ; the heart's action 
is tumultuous and the pulse is small. Sometimes the urinary and 
intestinal evacuations are involuntarily discharged and the semen is 
ejaculated. This stage continues from one to ten minutes. 

After the subsidence of the convulsive movements, complete relax- 
ation of all the muscles takes place. Eespiration becomes easy, the 
duskiness of the face disappears, and consciousness is either fully 
restored or the patient falls into a deep sleep, from which he awakes 
somewhat confused in mind. 

Petit Mai. The principal symptoms of the lighter forms of epilepsy 
are dizziness, momentary loss of consciousness (which is not always 
complete), and twitchiDg of some of the muscles. It would be difficult 
to pronounce with certainty upon the nature of some of these minor 
attacks were it not for the fact that they often change into the more 
severe forms, or alternate with them. Patients subject to petit mal 
not infrequently perform strange acts during this condition of which 
they retain no recollection. Trousseau relates the case of a judge 
who, in open court, would leave the bench and answer a call of 
nature in a corner of the room and then return to his seat in an 
unconcerned manner. Very little attention is usually paid to these 
"faints" or "spells," until they occur with great frequency and alarm 
the patient or his friends. 

Precursory Symptoms. Nearly one-half of the cases of epileptic 
seizures are immediately preceded by vague sensory disturbances or 
"warnings." These epileptic aurae, as they are called, are of a 
diversified character. Hughlings Jackson has lately made them the 
subject of an interesting investigation. 

The Epigastric Aura is the most common of all the precursory 
symptoms. It consists of an uneasy sensation in the region of the 
stomach, which patients describe as travelling upward and causing 
a feeling of tightness in the throat. Loss of consciousness immediately 
ensues. It is highly probable that disturbance of the pneumogastric 
nerve underlies the different aurae that are felt in the epigastrium, 
the chest and throat, and occasionally induce nausea, vomiting, a 
choking sensation, dyspnoea, and violent palpitations of the heart. 

The aurse referred to the extremities appear to resemble the 
sensations of tingling, creeping and numbness. They are frequently 



138 MANUAL OF NERVOUS DISEASES. 

associated with motor disturbances of these parts, and of the face 
and tongue — such as tremor, twitching of the muscles, and cramp. 

Auras of the special senses are not common. Visual auras are 
manifested by dimness of sight, diplopia, total blindness, pain in the 
eyeballs, flashes of light, colored flames, etc. The auditory auras 
consist of hearing of strange sounds and noises. 

The cephalic disturbances, headache and vertigo, are not usually 
attended by other forms of auras. Some patients experience the 
sensation as if the head were heavily pressed by a weight or crushed 
in. An epileptic under my notice always has the sensation of a 
smart slap on the side of the face immediately before an attack. 

Among the psychical auras, none is more common than an 
unaccountable terror that seizes the patient. Sometimes they are of 
a pleasant kind. One of my patients, a young woman who is subject 
to frequent attacks of grand mal, is occasionally thrown into an 
ecstatic condition. During one of these morbid mental states she 
waved her hand as if requesting me to stand aside, and then pointed 
to a part of the room where she located visions of extended lawns, 
beautiful flowers, clusters of grapes and wide -spreading trees. 

POST-EPILEPTICAL CONDITION. 

Psychical phenomena are more frequently witnessed in persons who 
are subject to minor than to severe attacks. Perhaps it is more 
proper to say that they form a part of petit mal. It is of great 
importance to recognize the nature of these mental disturbances, for 
they may be the only manifestations of the disease. In the majority 
of cases they consist of automatic acts of which the patient is 
oblivious, although his voluntary power may not be completely in 
abeyance at the time. Dr. Gowers relates the case of a carman who, 
after an attack of epilepsy, drove through the most crowded parts of 
London for an hour, without an accident, and retained no recollection 
of it afterward. One of my patients, a colored boy, often falls into 
the hands of the police for exposing his person in the public streets 
after an epileptic fit. 

Epileptic Mania. 

Alienists recognize a form of transitory insanity of an epileptic 
character, during which a person may commit flagrant and criminal 
acts. Great caution is required in estimating correctly the nature of 



THE CLASSICAL NEUROSES. 139 

this species of alienation. The principal criterion upon which a 
medical man must rely, in forming his judgment as to the character 
of the alleged manifestation of insanity, relates to the very short 
duration of the maniacal paroxysm, the utter want of recollection of 
what has happened during the state of excitement, and a history of 
similar attacks. The occurrence of epileptic fits subsequent to the 
overt act will naturally strengthen the diagnosis of epileptic mania. 

Inter-epileptic Condition. 

The mental deterioration due to the epileptic diathesis is shown 
by the large number of persons afflicted with this disease who yearly 
find their way into insane asylums. According to the statistics 
reported by Russel Reynolds, only thirty-eight per cent, of his epileptic 
patients were free from psychical disturbances. Close observers 
maintain that epileptics whose intellect is apparently not affected, 
show, nevertheless, some evidences of an abnormal mental state, 
which is only recognized within the privacy of family life. 

The protracted duration of the disease is not the only factor in the 
mental failure, for in many instances the deterioration is already 
noticeable at an early date. This impairment of the mind manifests 
itself at the beginning by defect of memory and incapacity of 
sustaining intellectual efforts. It ends in complete imbecility. Milder 
cases are mostly marked by emotional disturbances and unusual 
fluctuations of the mood and temper, with a tendency to a settled 
melancholy. 

Etiology. 

Sex. The predisponent influence of sex is difficult to determine in 
the face of the discrepancies of statistical inquiries. Whilst French 
authors find a preponderance of the disease in the female sex, 
English authors assign it to the male. Echeverria coincides with the 
latter, which accords with the results of American statistics. 

Age. Many cases of epilepsy date their first onset from early 
infancy. The influence of age is also shown by the frequent 
development of the malady at the period of puberty. 

Heredity. The evidences of a hereditary tendency are decisive, 
the proportion of cases traced to this cause being about 30 per cent. 
This figure is undoubtedly below the average, for there is a natural 
unwillingness on the part of patients and their relatives to give the 



14:0 MANUAL OF NERVOUS DISEASES. 

desired information. The family history of epileptics often elicits 
the important fact that some of its members have been affected by 
allied nervous diseases, — insanity, chorea, intemperance. 

Exciting Causes. When speaking of the exciting causes of epilepsy, 
it must be understood that they are supposed to act upon an unstable 
nervous system. At the head of these immediate causes stands 
sudden emotional excitement. A fright in children and nervous 
females is itself a paroxysm, which, in its visible effects, strongly 
resembles a convulsive attack. Mental shocks of any kind occurring 
at the period of adolescence, when the nervous and muscular 
apparatuses are at any rate inclined to be easily thrown off their 
balance, exert just such a morbid influence that may at once initiate 
life-long epilepsy. 

Next in order of frequency are injuries to the head, especially 
falls and blows. The occurrence of a fit from these traumatic causes 
is not seldom postponed for days and weeks. In cases of this 
character that gave opportunity for post-mortem examination, no 
gross lesions were found in the nervous apparatus. 

Menstrual disturbances are accused of being connected with the 
first appearance of fits in very young girls. The expectation that the 
establishment of the normal flow will put a stop to the fits is not 
sustained by experience. 

Opinions are divided on the question whether epilepsy is unusually 
common among the intemperate. Echeverria has the following on 
this mooted point : " On the whole, I deem that the greater prevalence 
of nervous diseases now observed, acknowledges among the primary 
agencies the wide-spread abuse of alcoholics." The experience of 
other observers does not coincide with this statement. In fact, the 
number of persons affected with epilepsy is insignificant when 
compared with the number of persons addicted to the immoderate 
use of alcoholic stimulants. 

The same estimate is also applicable to the alleged frequency of 
masturbation as an exciting cause of epilepsy. It is well known, 
however, that epileptics are much given to the practice of onanism. 

Pathology. 

Unimportant anatomical changes affecting the meninges and 
cerebral bloodvessels are often enough found in long-standing cases 
of epilepsy, but they are of a secondary character. No significance 



THE CLASSICAL NEUROSES. 141 

attaches to the intracranial venous congestion usually observed in 
persons who have died during a fit. As a general rule there is an 
entire absence of gross anatomical lesions in the nerve centers ; and 
thus far the microscope has failed to detect in them any minute 
histological changes. Induration of the cornu ammonis has 
recently been found to occur in no inconsiderable number of cases. 
It is reserved for future investigations to determine what weight is 
to be given to this morbid alteration. Much has been accomplished 
of late in the way of experiment to gain an insight into the epileptic 
phenomena. A satisfactory answer to the two following questions, 
based upon physiological and pathological data, would, in a great 
measure, clear up the whole subject of epilepsy : Where is the seat, 
and what is the mechanism of an epileptic seizure ? 

There is a general agreement that the seat of the disease is in the 
grey matter of the brain. The spinal cord acts merely as a conductor. 
But as regards the particular part of the brain which is the point of 
departure of the epileptic paroxysm, opinions differ. The majority 
of English neurologists incline to the view that in most cases it is 
the cortex of the hemispheres, and only exceptionally the medulla 
oblongata, which is primarily involved. This view is supposed to be 
sustained by the consideration that the loss of consciousness being 
purely a mental symptom, the change must necessarily affect the 
cortex ; and, furthermore, there is no need to conceive of a change 
taking place in any other nerve cen fcer to account for the occurrence 
of the spasmodic phenomena, since Ferrier has shown that irritation 
of the motor region of the cortex causes convulsive movements. 
Clinical observations also point to changes in the cortical centers, for 
it is an important fact that epileptical seizures are often preceded by 
psychical symptoms and disturbances of the special senses. This 
does not exclude the probability that epileptic paroxysms occasionally 
start from the medulla. Indeed, general convulsions are always 
propagated by this great reflex center; but this is no proof that this 
lower nerve center is the primary seat of the disease. Concerning 
the convulsion, we may readily accept the opinion of Hughlings 
Jackson, that it is the phenomenon of an occasional discharge of 
nerve tissue (no doubt of grey matter). It points not to " destroying " 
lesions, but to unstable nerve tissue — to "functional changes." In 
reference to the pathological process by which such changes are 
brought about, he adds "we have no clue." The theory of the 
unstable equilibrium of grey matter, as Dr. Growers remarks, adapts 



142 MANUAL OF NERVOUS DISEASES. 

itself beautifully to the explanation of the phenomena of epilepsy. 
The liberation of energy going on in every nerve cell is a physiological 
fact. Now, it is not necessary to assume that a convulsive attack 
implies increase of energy; on the contrary, the existence of the 
epileptic diathesis rather points in the opposite direction, and this 
naturally leads to the inference that a want of resistance in the nerve 
cell — its diminished " inhibitory " power — favors the ready discharge 
of nerve force. 

A theory differing in many respects from the foregoing is princi- 
pally advocated by German authors. The following synopsis, based 
on the elaborate statement of Nothnagel, embodies its salient points : 
Experimental investigations show that convulsive movements resem- 
bling those of epilepsy may be produced in animals so long as the 
pons and the medulla remain uninjured, though every other part of 
the brain be removed. Spasms of the extremities and of the trunk 
ensue when the brain alone is irritated. That both of these nerve 
masses are involved is evident from the fact that the motor nuclei 
of the nerves situated in the floor of the fourth ventricle are all 
affected in an epileptic attack. In order to understand the mechanism 
which arrests the functional activity of the hemispheres during the 
state of unconsciousness, we must again interrogate the teachings of 
experiment. Kussmaul and Tenner have shown that the sudden 
occurrence of cerebral anaemia induces all the symptoms of an 
epileptic fit. This happens whether the animal be bled to death or 
a large artery be compressed. Now the pallor of the face and the 
dilatation of the pupils, observable in many cases of epilepsy, are 
obviously the signs of cerebral anaemia. This abnormal condition 
of the intracranial circulation is explicable on the supposition that 
excitation of the cervical sympathetic ganglia (which contain most 
of the vaso-motor nerves that go to the cerebral vessels) causes 
spasmodic constriction of their walls. An observation of Brown - 
Sequard lends weighty support to this opinion. In guinea-pigs 
which he had rendered epileptic by his usual method he noticed 
narrowing of the vessels of the pia during the fits. But it may be 
asked, if it be granted that cerebral anaemia sufficiently accounts for 
the comatose condition, how is it with the other phenomenon of the 
epileptic seizure — the convulsive movements ? There is nothing to 
invalidate the assumption that excitation of both the vaso-motor 
center and the central motor apparatus constitute coordinate factors 
of the epileptic paroxysm. Such a view accords well with clinical 



THE CLASSICAL NEUROSES. 143 

facts. There are forms of petit mal in which mental confusion or 
local spasm is the only symptom. The inference that one of the 
nerve centers is here exclusively affected can hardly be avoided. 

The most important part of the inquiry relates to the nature of the 
exciting cause which acts upon the "convulsive " center. It may be 
thought that the "warning " symptoms, which partake of the character 
of sensory disturbances, initiate an epileptic attack analogous to the 
effects of a peripheral irritation, which we know may evoke reflex 
muscular contractions. But it is just as difficult to account for the 
aura as for the epileptic seizure itself. It is the nature of that morbid 
excitation which, at regular or irregular periods and in the midst of 
apparent sound health, induces convulsive paroxysms which still 
remains inexplicable. 

Diagnosis. Considerable care is sometimes required in dis- 
criminating between epilepsy and convulsive seizures depending 
upon organic disease of the brain and blood-poisoning. The minor 
attacks offer especial difficulties to diagnosis. 

Nocturnal epilepsy may exist for years without being suspected by 
the patient or his family. The signs of the concealed malady are a 
constant sore tongue, ecchymotic spots on the neck, suffused eyes, 
and a feeling of languor in the morning. Wetting of the bed is 
occasionally of similar significance. 

No little embarrassment is sometimes felt in estimating the real 
character of infantile convulsions. When no palpable cause can be 
assigned for their recurrence, it is well to bear in mind that epilepsy 
not uncommonly develops at a very early age. Spasmodic seizures 
due to dentition or resulting from gastric or intestinal derangements, 
or caused by the passage of a urinary calculus, cease upon the removal 
of the cause, and are of a longer duration than the convulsions of 
idiopathic epilepsy. 

Diseases of the brain and its membranes, but more particularly 
intracranial tumors, cerebral abscess, embolism, and syphilis of the 
nervous system are frequently attended by epileptiform attacks. The 
distinction from true epilepsy rests upon the clinical history of the 
case and the consideration of the concomitant symptoms. 

Fainting fits bear some resemblance to minor attacks of epilepsy. 
But syncope can usually be traced to some depressing influence, 
physical or mental. There is an absence of aura, and the loss of 
consciousness is not so sudden and complete as in epilepsy. 



M4: MANUAL OF NERVOUS DISEASES. 

Vertigo may be mistaken for that form of petit mal which 
Trousseau calls "vertigenous epilepsy." In ordinary vertigo there 
is a sense of " falling over," and the patient grasps about for some 
support; but there is no actual unconsciousness or un forge tfulness 
of what has happened. 

Hysterical Convulsions. No one who has ever witnessed a hysterical 
fit will confound it with a true epileptic seizure. The tumultuous 
and not incoordinate movements of the hysterical paroxysms, their 
protracted duration, the incomplete unconsciousness, the noisy 
behavior of the patient, and the unchanged appearance of the 
countenance, contrast strongly with the abrupt onset of epileptic 
seizure, its short duration, the profound coma, the biting of the 
tongue, the lividity of the face and the distortion of the features. 
The real diagnostic difficulty is encountered in those rare instances 
of " hystero-epilepsy " in which the symptoms are of a complex 
character. This subject will be more fully considered in its proper 
place. 

Renal Convulsions bear a close resemblance to those of idiopathic 
epilepsy. The distinction rests on the recognition of the primary 
disease. It should be remembered, however, that the granular 
disease of the kidneys which is particularly prone to cause 
epileptiform spasms, may exist for a long time without revealing its 
presence by any well-marked symptoms. The urine contains but a 
moderate amount of albumen, and at times it is altogether absent. 
An excited state of the heart's action, not depending upon valvular 
lesion, and the ursemic signs of headache, drowsiness and nausea 
preceding epileptiform attacks, point to the probable existence of 
renal disease. 

Peripheral Epilepsy. It is of great practical importance to 
recognize that variety of epilepsy which is due to some peripheral 
irritation, such as cicatrices, intestinal worms, etc. Cases of this 
nature promise good results from appropriate treatment. 

Simulation. The imitation of epileptic fits by malingerers cannot 
well deceive any one familiar with the peculiarities of the genuine 
disease. Impostors cannot produce at will dilatation of the pupils 
nor insensibility of the conjunctiva. 

Prognosis. There is seldom immediate danger to life even in very 
severe attacks of epilepsy. Death or injury from accidents during a 



THE CLASSICAL NEUROSES. 145 

fit is more to be feared. On the other hand, the prospect of a 
spontaneous cure is not encouraging. As a general rule it may be 
stated that the longer the disease has lasted the less chance there is 
of recovery. Symptomatic epilepsy from organic brain trouble, 
especially tumors, is absolutely of bad augury. The prognosis is 
more hopeful when the disease is due to intracranial syphilis. Attacks 
occurring at long intervals are more amenable to treatment than 
when they come on after brief intermissions. Minor attacks appear 
to be less influenced by remedies than the severe forms of epilepsy. 

Treatment. The physician, since the introduction of the bromides 
into the practice/ feels less despondent in undertaking the treatment 
of idiopathic epilepsy than formerly. That these preparations 
exercise a controlling influence in a large proportion of cases, and 
occasionally effect a permanent cure, there can be no doubt. Much 
depends upon the dosage and the persistence in the administration of 
these drugs. It is best to commence with fifteen or twenty grains of 
any of the bromides thrice daily, and to gradually increase the dose to 
2 drachms per diem. The maximum dose of four drachms in twenty- 
four hours may be ventured upon in cases of exceptional severity and 
obstinacy. Small quantities of the bromide suffice so soon as the 
paroxysms have been arrested for a reasonable time ; but on their 
recurrence, which unfortunately is but too often the case, larger 
doses must again be given. There is no difference in the therapeutical 
qualities of the several preparations of the bromides. The potassium 
bromide answers every purpose. Perhaps the sodium bromide is 
better suited to delicate stomachs. Brown -Sequard prefers a combi- 
nation of the ammonia and potassium bromide. Weir Mitchell 
recommends the bromide of lithium, as it contains the largest 
percentage of bromine. Nocturnal epilepsy calls for large doses 
immediately before going to bed. 

Belladonna formerly enjoyed a high reputation in epilepsy. It is 
certainly inferior to the bromides. Ten drops of the tincture, or the 
one hundred and twentieth of a grain of atropia night and morning 
is the usual dose. This remedy appears to act more favorably in 
minor attacks. A combination of belladonna and one of the bromides 
is highly spoken of by Dr. Gowers. 

Oxide of zinc is an old remedy for fits. From five to seven grains 
twice a day may be given for weeks and months. Few stomachs can 
bear this drug in larger doses. 



146 MANUAL OF NERVOUS DISEASES. 

Nitrite of amyl has lately been tried, but like so many other 
remedies for the cure of epilepsy, it has been undeservedly lauded. 

Iodide of potassium, in conjunction with a bromide, is indicated in 
syphilitic epilepsy. 

Iron and cod-liver oil are required in anaemia and general 
debility. 

The possible removal of the exciting cause demands the first 
attention. Surgical interference may become necessary, as the 
incision of a cicatrix involving a sensory nerve, or the extirpation of 
tumors, etc. 

Secondary epilepsy (Hughlings Jackson) resulting from organic 
disease of the nervous apparatus, calls for treatment of the primary 
affection. 

Quite recently Dr. W. Alexander has strongly advocated ligation of 
the vertebral arteries for the arrest of epileptic seizures. 

Chorea (St. Vitus' Dance). 

Clinical History. The initial symptoms of this disorder are 
usually misunderstood by parents and teachers. Children, who are 
principally affected by it, are frequently chided and even punished 
for having contracted certain awkward habits and for indulging in 
silly behavior. These little patients let things drop from their 
hands, make all kinds of grimaces, continually shrug their shoulders, 
scribble when required to write, and exhibit a constant restlessness. 
Before long, however, these irregular movements and contortions are 
observed to be involuntary, and to become general and aggravated as 
the disorder progresses. Volitional acts always start the jerks, but 
they also come on spontaneously. In severe cases the whole body 
wriggles, and is forced to assume, with short respites, grotesque 
attitudes. Nearly every voluntary muscle may show incoordinate 
action. The eyes rotate, the tongue is suddenly thrust forward and 
is as suddenly withdrawn. Speech becomes affected, swallowing is 
difficult, strange sounds are uttered from spasmodic action of the 
laryngeal muscles, and the respiration is irregular. 

The choreic movements usually begin in the hand or in the face 
or shoulder of one side, and then extend to other parts of the body. 
In hemichorea, as the name imports, the motor disturbances remain 
unilateral. Increase of sensibility is often noticed at the outset of 
the disorder, and later in its course muscular weakness and some 



THE CLASSICAL NEUROSES. 147 

degree of mental obtuseness are observed. During sleep there is a 
cessation of the abnormal movements, but the patient is disturbed 
by starts that shorten his rest. It is remarkable that choreic 
persons never complain of a sense of fatigue caused by the incessant 
jactitations. 

When the disorder is of a violent character it renders the patient 
completely helpless. He is unable to keep on his feet ; he must be 
fed and dressed; deglutition is hindered, and speech is almost 
impossible. The constant friction of the elbows and knees against 
hard substances produces abrasions of the skin. Sometimes the 
jerking and tossing are so violent that the patient has to be fastened 
down to his bed. 

Etiology. Chorea is a chronic disease. It is most frequently 
observed to attack children between the periods of the first dentition 
and puberty, and predominates in the female sex. A direct hereditary 
transmission of the malady cannot be shown to exist; but it must 
be assumed that a constitutional susceptibility predisposes to its 
development. Psychical disturbances, particularly fright, act as 
exciting causes. A similar mental influence operates in those singular 
cases which are ascribed to imitation. Chorea occurring during 
pregnancy or due to intestinal irritation, especially the presence of 
worms, is evidently of a reflex character. A causal relation between 
chorea and rheumatism is now generally conceded to obtain in a 
considerable number of cases. 

Pathology. Neither anatomical nor experimental investigations 
have thus far led to any satisfactory results respecting the nature of 
chorea. Foyers of softening, probably due to capillary embolism, 
have been found in different parts of the brain, though mostly in the 
basal ganglia. In other instances the morbid changes involved the 
spinal cord, consisting of hyperplasia of the connective tissue. 
Pathological alterations affecting peripheral nerves are also mentioned. 
Some observers lay particular stress on the post-mortem evidences of 
endocarditis in connection with chorea. This concurrence throws 
much light upon the source of embolic softening and hemorrhage of 
the nerve centers which are sometimes found in persons who have 
died of chorea, and suggests a relationship between this disorder and 
rheumatism. The facts which speak in favor of a cerebral origin of 
chorea are the occasional localization of lesions in the basal ganglia, 
the occurrence of hemichorea and the mental hebitude. 



148 MANUAL OF NERVOUS DISEASES. 

Diagnosis. The symptomatology of chorea is of so marked a 
character that it is at once recognized. The tremor of paralysis 
agitans bears but a faint resemblance to choreic jerks. Certain 
diseases of the brain, especially tumors, occasionally give rise to 
choreiform movements ; but the recognition of the primary disease 
will at once remove the uncertainty. 

German authors group under the name of "chorea magna" a class 
of cases characterized by an irresistible motor impulse which leads 
to the exhibition of extraordinary involuntary movements. The 
"dancing mania," "tarantism " and "electric chorea," which prevailed 
from time to time in an epidemic form in Europe, belong to this 
category. Motor disturbances of an analogous and curious character 
are occasionally brought under notice. There is reason to believe 
that many of these morbid phenomena are allied to hysterical, 
maniacal or epileptic paroxysms ; or, perhaps, depend upon a patho- 
logical condition somewhat resembling the psychical exaltation in 
trance, ecstasy, etc. A form of motor disturbance belonging to this 
species is known by the name of " saltatory cramp." 

The following brief notes of a few cases which I had an 
opportunity to observe, will exemplify the character of these strange 
disorders : 

A girl nine years of age had been subject for the last three years to ' ' nervous 
attacks," (as her mother calls them), that present the following features: The 
child would suddenly begin to cry like an animal and then contort its body, 
throwing about the arms, kicking at the furniture, jumping in a "leap-frog" 
fashion, riding upon chairs, climbing on the table, rolling about on the floor, 
scratching the walls, endeavoring to tear its clothing and to perform many other 
unusual acts. During the paroxysms there is a constant discharge of saliva, the 
eyes are suffused and urine dribbles away. Consciousness remains intact. Any 
attempt to prevent the child from going through these antics increases their 
violence and duration. 

A young man twenty-three years of age suffered at irregular periods from 
violent palpitations of the heart, attended by rapid rotatory movements of the 
head. These movements were not observed during sleep. In other respects he 
appeared to enjoy good health. Exploration of the chest detected no signs of 
organic disease of the heart. Under the use of valerianate of zinc, decided 
improvement of the symptoms was noticed, so that the patient did not present 
himself at the dispensary for the next three months. When I saw him again 
a new set of symptoms had made their appearance. He is now frequently 
attacked by an indescribable sensation in the cardiac region, which travels upward 
in the direction of the left shoulder, arm and hand. This is immediately 
succeeded by rhythmical movements of the affected extremity from right to left, 



THE CLASSICAL NEUROSES. 149 

and accompanied by a sensation which the patient compares to electric shocks. 
At no time is there any loss of consciousness. The family history of the patient 
is not good. His oldest brother died in an insane asylum after having been 
afflicted with life-long epilepsy. A younger brother has a withered leg which 
dates from his early infancy. A sister suffers from hysterical convulsions. I 
forgot to mention that compression of the carotids momentarily arrests the 
abnormal movements. Thinking that this case might possibly be of an epileptic 
nature, I ordered a bromide with decided benefit. 

It is hardly necessary to add that cases of this description totally 
differ from chorea. 

The Prognosis of chorea is favorable. A fatal termination is the 
rare exception. Death may, however, follow from some serious lesion 
of the nerve centers, or from exhaustion brought on by the prolonged 
continuation of the disorder. Its average duration is about three 
months; but it may range from six weeks to six months. 

Treatment. It is not easy to decide upon the efficacy of any 
particular remedy in the treatment of chorea. Mild cases require 
little medicine. The appearance of anaemia calls for ferruginous 
preparations. Intestinal irritation from worms or any other source 
must be met with the appropriate remedies. Choreic children should 
not be allowed to attend school. Quiet and rest I have found to 
abate the disorder. Cold sponging and the application of the galvanic 
current to the spine at the early stage of the malady, sometimes 
moderates the violence of the movements. Arsenic is a favorite 
remedy in chorea. It is usually given in the form of Fowler's 
solution. Sulphate of zinc and strychnia also enjoy the reputation 
of shortening the attack. 



CHAPTER XIII. 
HYSTERIA. 

Etiology. Whilst pathological anatomy throws no light on the 
nature of hysteria, many an ingenious theory has been proposed to 
clear up the mass of singular and bizarre phenomena that characterize 
this protean malady. Clinical facts lead to the conclusion that 
hysterical persons suffer from an instability of the nervous system 
which constitutes the fruitful source of their manifold ailments. This 
neuropathic condition, or more specifically, this hysterical diathesis, 
greatly preponderates in the female sex. Heredity exercises a decided 
influence in favoring its development. It is easy to understand why 
the delicate and impressionable structure of the nervous apparatus 
in women should readily react in an undue manner to exciting causes 
which hardly affect the sterner sex. Hysterical symptoms in girls 
frequently make their first appearance at the period of pubescence. 
Of a similar influence is the recurrence of the menstrual molimen. 
Experience teaches that uterine and ovarian trouble, anaemia and 
chlorosis, not seldom lay the foundation of a life-long hysteria. 
Boys of a tender age sometimes exhibit its well-known phenomena. 
Considerable influence in establishing this malady must also be 
attributed to the injurious effects of mental excitement, especially 
those of a depressing nature, such as deep anxiety, secret sorrow, 
disappointment, harsh treatment, etc. The mistaken and ill-directed 
training of little girls who give early intimation of a disposition 
which betrays odd or morbid susceptibilities, is much to be blamed. 
It is alleged that the frivolities and artificial excitement in which 
females in affluent circumstances are apt to indulge, augment the 
number of hysterical patients ; but women in humble walks of life 
are certainly not exempt. 

Clinical History. Considering the wide range of the hysterical 
symptoms and their diversity, even in the same patient, it is a 
questionable undertaking to essay the description of a typical case of 
this disorder. It is more useful to point out those significant 



HYSTERIA. 151 

phenomena which betray the existence of the hysterical diathesis ; 
but it must be observed at the outset that the morbid manifestations 
are not distinguished by any intrinsic peculiarity ; their true nature 
is rather recognized by the disproportion existing between their 
apparent intensity and their unsubstantial basis, and not less also by 
their association with other sets of symptoms, well known to every 
experienced physician. 

Hyperesthesia is, perhaps, one of the most frequent ailments of 
hysterical females. The muscular as well as the cutaneous sensibility 
is morbidly acute. Touch or pressure in many parts of the body 
elicits pain. The movements of the limbs are sometimes attended 
by such extreme pain that a patient cannot be persuaded to leave her 
bed or sofa. The head, the shoulders, the chest, the back and the 
abdominal walls appear to be highly sensitive, which suggests to the 
alarmed patient the existence of some serious internal disease. Sir 
Benjamin Brodie first drew attention to a form of joint affection 
simulating arthritis which occasionally develops in hysterical 
females. 

Few hysterical females are exempt from some species of neuralgia. 
"Clavus hystericus" signifies an intense pain limited to a small spot 
along the sagittal suture. Intercostal pain is probably the most 
constant species of neuralgia in hysteria. Ovarialgia may acquire 
such a great intensity as to bring on a hysterical fit. 

Uncomplicated anaesthesia of the left side of the body is peculiar 
to hysteria. The electro-cutaneous sensibility is at the same time 
much diminished. The anaesthesia sometimes shifts spontaneously. 
This change, according to recent experiments, or the "trans- 
ference," as it is called, occasionally follows the application of certain 
metallic disks. Insensibility to pain is not seldom associated with 
the cutaneous anaesthesia. 

The local spasms which so frequently harass the hysterical are of 
great diagnostic importance. The phrase "globus hystericus" 
expresses the sensation of a ball rising in the throat. It is produced 
by constriction of the pharynx and oesophagus, and causes difficulty 
of deglutition. Spasm of the glottis causes a choking sensation. 
Convulsive laughter, sobbing and crying, frequently terminate or 
may replace a hysterical fit. An incessant cough like the sound of 
a trumpet is known as the hysterical cough. Asthmatic attacks, 
hiccoughs, the eructation of gas from the stomach, movement of the 
gases in the intestines (borborygmus), vaginismus and vesical 
tenesmus, complete the list of these local spasms. 



152 MANUAL OF NERVOUS DISEASES. 

The gastro-intestinal disturbances of hysteria comprise disgust for 
certain articles of food in common use, disinclination for regular 
meals, or a raving appetite. Obstinate vomiting without an assignable 
cause is one of the most intractable symptoms of hysteria. This, and 
habitual constipation of the bowels, in hysterical females seem to 
baffle all the ordinary remedies. 

Among the host of hysterical symptoms must also be mentioned 
epigastric pulsation, which may counterfeit aneurism. Menstrual 
irregularity is probably more frequently the effect than the cause of 
hysteria. 

Hysterical Convulsions. Not every hysterical female is subject to 
hysterical convulsions, but a paroxysm is prone to develop under 
the influence of strong mental excitement. A hysterical fit may 
set in rapidly, though in many cases there is a brief prodromic 
stage characterized by a feeling of languor, epigastric uneasiness, a 
choking sensation, fluttering at the heart and vague pains in the 
limbs. The fit usually begins with a partial loss of consciousness, 
the patient flings herself on the bed or falls with some deliberation 
to the floor ; frequently she screams or becomes noisy, which is kept 
up during the attack. Spasms of an unrhythmical character quickly 
supervene ; the limbs are wildly thrown about, the eyes turned up 
or firmly closed, and various other grimaces of the face may be noticed. 
The hysterical fit does not always present such a violent and 
tumultuous character. Frequently the consciousness remains free, 
and the patient complains of severe headache and epigastric pain. 
When the spasmodic movements are limited to the hands and feet, 
they are usually in a state of tetanic contraction, being either firmly 
flexed or extended. Hysterical convulsions may be indefinitely 
prolonged. Their termination is usually announced by a loud escape 
of gas or air from the stomach, a shower of tears and a copious flow 
of limpid urine. 

A physician who has once watched a hysterical fit would be 
inexcusable if he should confound it with an epileptic seizure. If 
the epileptic utters a shrill cry it is only at the onset of the attack. 
His loss of consciousness is complete and he falls to the ground 
headlong and unprepared. Epileptic spasms present the typical 
characters of tonic and clonic contractions. There is biting of the 
tongue, bloody, frothy mucus at the mouth, the face presents a 
hideous appearance, the pupils are usually dilated, and the whole 
attack is of short duration. All these characteristic clinical features 



HYSTERIA. 153 

are wanting in the hysterical fit. Still a case now and then comes 
under notice in which the hysterical and epileptic elements seem to 
be blended. French authors draw frightful pictures of these so-called 
cases of " hystero-epilepsy." 

Hysterical Paralysis. Motor paralysis is the most serious 
symptom of hysteria. Briquet observed various forms of paralysis 
in a large number of his cases. The paralysis may assume the 
hemiplegic, the paraplegic and the peripheral type. Hysterical 
aphonia is due to paralysis of some of the muscles of the vocal cords. 
Paralysis of the bladder is also frequently observed. Electrical 
exploration affords much assistance in recognizing the hysterical 
character of these motor disturbances. The electro-muscular 
contractility is usually found intact, whilst the electro- cutaneous 
sensibility is much diminished. It is also a curious fact in the 
history of hysterical paralysis that the muscular power is sometimes 
suddenly restored without an apparent cause, and as unexpectedly 
again impaired. 

Mental Disorders of Hysteria. Psychical disturbances are seldom 
wanting in marked cases of hysteria. It is particularly the sphere of 
emotional life, the sensibilities, the mood, temper and disposition 
which manifest a morbid tendency. The lower fundamental 
elements of mental activity seem to exercise a controlling influence 
and to react in an abnormal manner. Slight impressions produce an 
exaggerated effect; the propensities, the inclinations and the will are 
perverted; there are an obstinacy and waywardness which, to the inex- 
perienced, appear unaccountable. The undue mobility of the feelings 
is exhibited in the sudden transitions from gayety to sadness. There 
is a passiveness to the play of fancy; singular likes and dislikes; 
sometimes decided apathy and stolid indifference, or a morbid desire 
to attract attention and to create sympathy and interest. Hysterical 
persons who are more or less affected in this manner are an enigma 
to their friends and acquaintances, and a plague and a source of 
mortification to their families. The higher grade of such psychical 
abnormities, which is fortunately not common, may assume the 
character of moral obliquity, or terminate in the development of 
insanity. Many are the transformations of the hysterical frame of 
mind. Weir Mitchell has published a series of remarkable and 
instructive cases, illustrating the diversified and hidden character of 
hysterical aberrations. On the other hand, every strange and 



154 MANUAL OF NERVOUS DISEASES. 

inexplicable phenomenon of a neuropathic nature is liable to be 
labelled as hysteria, though nothing is gained by the liberal use 
of this elastic term. 

Diagnosis and Prognosis. Little of any importance remains to be 
said under the head of diagnosis. There is one observation, however, 
which appears to be pertinent in this connection. Hysterical people, 
like ordinary mortals, are subject to diseases of the nervous system 
which stand in no relation to hysteria, and it must be borne in mind 
that in nervous females the symptoms pertaining to grave affections 
are apt to assume a deceptive character. Hysteria is certainly not a 
serious malady, but it is one of the most distressing inflictions to 
which the female sex is liable, and to deal with it successfully 
requires a peculiar tact on the part of the physician which not every 
one has at his command. 

Treatment. A protest must be entered against the cruel indifference 
with which the ever-returning ills and ailments of the hysterical are 
generally regarded. The physician who shares in this error is 
certainly blamable. It is true, hysterical women are exceedingly 
troublesome patients, and often try the equanimity of the medical 
attendant to the utmost ; but if he succeeds in gaining their confidence, 
which can be best accomplished by an unaffected sympathy combined 
with firmness, he will have comparatively an easy task before him. 
Banter and ridicule are entirely out of place. The opposite course 
of an undue display of anxiety and the slavish readiness to satisfy 
every whim, which fond mothers are apt to manifest, must equally be 
deprecated. 

Strict inquiry should be instituted concerning the uterine functions, 
but too much should not be made of slight disturbances. 

The digestive functions require attention. Better results are 
obtained if the patient can be weaned from the morbid anxiety 
respecting the gastric troubles, than from the reputed anti-dyspeptic 
remedies. A course of some of the mild mineral waters suits the 
torpid state of the bowels. 

Treatment is sometimes very satisfactory where hysteria is attended 
by anaemia or chlorosis. Blaud's pills, which are composed of equal 
parts of sulphate of iron and potassium carbonate, are highly 
recommended by Niemayer. They should be given in large doses 
and for a lengthy period. Sea-bathing and the electric bath may 
also prove of service. 



HYSTERIA. 155 

Women of a plethoric habit require an opposite course of treatment. 
The sensations of fullness of the head and heaviness of the limbs are 
sometimes relieved by leeches to the head or cupping over the spine. 
Green tea and coffee should be prohibited. 

When there exists a superabundance of fat of a flabby kind it is 
advisable to reduce its bulk by a spare diet, and then gradually to 
improve the general nutrition by a more generous diet, which should 
at first be principally composed of milk. 

Anti- Hysterical Remedies. Formerly when the diagnosis of hysteria 
was made, it implied assafoetida and valerian, now it means the 
bromides. Valerian is the least objectionable when something has to 
be done against trifling and evanescent symptoms. The bromide is 
undoubtedly a capital remedy, independent of its calming influence, 
as it possesses the additional advantage of superseding the use of 
narcotics. The latter should be sparingly given, or not at all, for 
fear of inducing a vicious habit. For the same reason it is un ad- 
visable to be liberal with wine or brandy, though the evident debility 
of many hysterical persons seems to call for stimulants. 

Some of the popular measures for cutting short a hysterical fit are 
frequently quite effective, but stuffing the mouth w T ith salt or throwing 
a pailful of water over the head of the patient should not have the 
sanction of the physician. Violent measures are at any rate not 
required in an affection which ceases of its own accord and is 
unattended by danger. Compression of the ovaries, by applying the 
closed hand firmly to the groin, sometimes succeeds in arresting the 
convulsions. Hysterical spasms, which are attended by pain usually 
in the epigastric region, can be promptly relieved by a hypodermic 
injection of morphia. 

Good results may be expected from the electrical treatment in the 
different forms of hysterical paralysis. The interrupted and constant 
currents should both be tried. Rapid improvement is occasionally 
witnessed from the use of the electric brush in hysterical anaesthesia. 
Hyperesthesia is relieved by weak galvanic currents. 

Spinal Irritation. 

There was a time when the disorder known as spinal irritation was 
thought to be of such frequent occurrence that extravagant notions 
were entertained of its importance as the common pathological factor 
of manifold forms of disease. A reaction took place when it was 



156 MANUAL OF NERVOUS DISEASES. 

found that spinal tenderness attends many affections of which it 
forms but an accessory symptom. Moreover, the same symptom is so 
frequently observed in that protean malady, hysteria, that the belief 
in the existence of spinal irritation as an independent disorder is 
generally abandoned by neurologists. But on the other hand it is 
hardly permissible to label every obscure nervous disorder with the 
convenient title, hysteria. It is equally unsatisfactory to theorize 
upon the possibility of a hyperaemic or anaemic condition of the cord 
as the anatomical basis of the so-called spinal irritation. In the 
meantime the physician in actual practice cannot ignore the fact that 
he has frequently to face groups of symptoms which appear to stand 
in no other relation to each other than their co-existence with spinal 
tenderness. The circumstance that eccentric pains and an exalted 
sensibility constitute the most constant concomitants of the sore 
vertebrae, tells strongly in favor of the assumption that the phrase 
spinal irritation implies a real disorder, at least of clinical 
importance. 

Patients are often unaware of the existence of this spinal tender- 
ness until it is elicited by pressing the fingers against some of the 
spinous processes, or passing a hot sponge along the spinal column. 
The tender points (points apophysaires) are usually limited to a few 
vertebrae in the cervical or dorsal, and less frequently in the lumbar 
regions. In severe cases the whole spine appears to be sore to the 
touch. This exalted sensibility not seldom occupies large areas of 
the cutaneous surface. 

Neuralgic pains are felt in different parts of the body. Their 
locality frequently corresponds to the distribution of sensory fibres 
that proceed from the tender portions of the spine. This explains 
the eccentric character of the pains. 

Local spasms, especially of the muscles of the lower extremities, 
are quite frequent. A crampy condition of the muscles of the neck 
gives rise to a distressing sensation of choking. A harassing cough 
and occasional attacks of dyspnoea which probably depend upon 
contractions of the laryngeal and respiratory muscles, cause much 
alarm to the patient. 

Additional symptoms more or less frequently attend the spinal 
tenderness which are as annoying to the patient as they are puzzling 
to the medical attendant. They principally consist of irritation of 
the bladder and vesical tenesmus ; palpitation, or rather a sensation 
of fluttering in the region of the heart; nausea, eructations and 



HYSTERIA. 157 

occasional vomiting; epigastric pulsation; faintness, vertigo, and a 
chilly feeling, alternating with hot flushing of the face. Continuous 
loss of sleep is a very distressing symptom in aggravated cases, 
causing a feeling of languor and depression, so that patients cannot 
be persuaded to leave their bed or lounge. 

Etiology. The frequent association of spinal irritation with 
hysteria points to a similarity of causative influences. Excessive 
physical exertion trying to the spine probably acts in many instances 
as an exciting cause. Austie says, " I believe the starting point of 
the disorder will very often be found in some strain or blow to the 
back." 

An obstinate case of spinal irritation some time ago came under 
my notice, which the young female patient attributed to the wearing 
of a shoulder brace (weighing nearly thirty pounds) for supposed 
curvature of the spine. 

Much stress is laid by some writers on the deleterious effects of 
sexual excesses, especially onanism, in developing the malady. It is 
also surmised that unconscious sexual irritation in women of pure 
mind exerts a similar morbid influence. 

Diagnosis. The diagnosis of spinal irritation requires considerable 
caution. The tenderness of the vertebrae must be distinguished from 
the pain attending organic affections of the spinal cord and disease 
of the vertebras. Mistakes are more frequently committed in misin- 
terpreting the eccentric pains which accompany obscure affections of 
the thoracic and abdominal viscera. The existence of paralysis 
excludes spinal irritation. The pain of neuralgia, unlike that of 
spinal irritation, is limited to the course of the affected nerve ; it is 
unilateral and not shifting. The pain of muscular rheumatism is 
increased by movement and pressure, and is of a diffused character. 

The close relationship existing between spinal irritation and 
hysteria is well expressed by Dr. Eadcliffe. " Spinal irritation," he 
says, " is hysteria plus spinal irritation." It may be here remarked 
in passing, that hysteria admits of such an expansive definition that 
this malady always obtrudes itself upon the attention whenever 
ill-defined groups of nervous symptoms are encountered. 

Prognosis. Although spinal irritation is a chronic disorder, 
exceedingly fluctuating in the severity of its symptoms, hard to deal 
with, and prone to relapses after the most encouraging improvement, 
it notwithstanding tends to recovery. 



158 MANUAL OF NERVOUS DISEASES. 

Treatment. The unsatisfactory results of the usual therapeutical 
measures directed against a class of symptoms of an obscure and shifting 
nature, leave much scope to the tact and judgment of the physician. 
As spinal irritation is a disorder frequently witnessed in females who 
have undergone much hardship in life, physical or mental, it is 
advisable to invigorate the general system by means of the approved 
tonics, iron, quinia, strychnia and cod-liver oil. To assist the effect 
of these remedies, a generous diet, rest and quiet must be enjoined. 
Blistering of the tender vertebras is universally recommended. I 
have found great benefit from the application of the electric brush to 
the hypersesthetic skin. All observers are agreed that alcoholic 
stimulants exert a decided beneficial influence in this disorder. 
Unfortunately the dangerous fascination of all kinds of spirituous 
liquors is a great drawback to their remedial virtues. The refreshing 
effect of general faradization is appreciated by most patients suffering 
from the malady. 

Neurasthenia. 

The late Dr. Beard of New York described, under the name of 
neurasthenia, a functional affection of the nervous system which he 
alleged to be extremely common among the adult male population of 
the United States. He says : " One reason why neurasthenia has 
been so long neglected is that the symptoms are in some instances so 
subtle and difficult of analysis and classification. One who has 
never seen and carefully examined a large number of cases of this 
disease, would not believe it possible that it could manifest itself in 
so many different ways." Erb devotes a short chapter to the 
discussion of this disorder, although he does not claim for it the 
multiplicity of symptoms which Dr. Beard has enumerated. 

Nearly all the morbid phenomena which are said to characterize 
neurasthenia are usually grouped under different affections, chiefly 
hysteria, spinal irritation and hypochondriasis. It will hardly be 
disputed that many vague and ill-defined symptoms come frequently 
under notice which cannot be satisfactorily referred to disorders 
of such uncertain pathology and inconstancy of clinical features. 
Experience fully sustains what physiological teaching leads us to 
expect, that numerous and diversified disorders of the nervous 
system are directly traceable to the depressing influences of physical 
over-exertion and mental strain. Whatever other causes may be 
assumed to favor their occurrence, and among these, seminal losses 



HYSTERIA. 159 

stand pre-eminent, it is but fair to consider nervous exhaustion a 
fruitful source of manifold disturbances. The practical importance 
of recognizing such a condition, under the many disguises it may 
assume, is apparent. 

Clinical History. Among the great array of subjective symptoms, 
variable and fluctuating in character, even in the same patient, there 
is none more constant and conspicuous than a feeling of muscular 
weakness and unusual tiredness. Of hardly less frequency is the 
existence of lumbar and dorsal pain, which often radiates to the 
occiput and vertex. Sometimes patients complain of a distressing 
feeling of constriction around the chest, or of a choky sensation, 
dyspnoea and cardiac excitement, associated with epigastric uneasiness 
and annoying eructations. The general sensibility is heightened, and 
gives rise to shifting pains of a neuralgic character in different parts 
of the body. Micturition and defecation may cause much discomfort. 
The sexual function, in many cases, is enfeebled. Young men in whom 
the latter symptom is associated with spermatorrhoea or nocturnal 
emissions, evince much apprehension of becoming the victims of serious 
spinal disease, or of being threatened with impotence and paralysis. 
Eeal paralysis does not occur, although neurasthenic persons are 
incapable of sustained muscular efforts, and are often troubled with 
the sensation of numbness, formication and coldness in the lower 
extremities. Under these circumstances a hypochondriac disposition 
is liable to develop. 

Neurasthenia is sometimes rapidly established in persons of a 
hereditary tendency to neurotic affections, but generally its progress 
is slow. 

Diagnosis. It is above all necessary in the diagnosis of this 
disorder to inquire into the previous history of the patient, his habits 
and present pursuits. A thorough examination and sifting of the 
symptoms must be instituted, as they may be easily mistaken for those 
of some serious organic disease, especially of the spinal cord. 

Treatment. Hygienic measures are of the first importance in the 
management of every case of neurasthenia. The patient must change 
that mode of life which led to brain exhaustion and spinal irritability. 
He may require absolute rest and quiet, or be benefited by exercise 
which does not cause fatigue. The recuperative influence of mountain 
air or a visit to the sea-shore should not be neglected. Sufficient 



160 MANUAL OF NEKVOUS DISEASES. 

sleep, substantial but easily digested food, and a judicious course of 
tonic remedies, especially iron, quinia and strychnia, complete the 
constitutional treatment. 

Much benefit is derived from the frequent sponging of the spine 
with sea salt water and friction with a rough towel. The restoration 
of the muscular vigor should be promoted by massage and general 
faradization. Decided relief of the spinal pain is sometimes obtained 
from the application of ether spray. 

Hypochondriasis. 

This disorder betrays an affinity to melancholia, inasmuch as the 
alteration common to both is characterized by a depressed condition 
of the mind and an excessive feeling of anxiety and apprehension. 
It would, nevertheless, be erroneous to class hypochrondriasis with 
insanity, for, although aggravated cases of the former exhibit much 
psychical disturbance, still the intelligence remains clear in the main, 
and no hallucinations and delusions develop. The essential clinical 
feature of hypochondriasis is a morbid disposition to fix the attention 
on slight ailments, which are magnified and falsely interpreted by the 
patient. The anomalous sensations of which he constantly complains 
are undoubtedly real, they absorb his thoughts, leave him no rest, 
and render him sad, morose and peevish. In addition to these vague 
and indistinct feelings, which probably have their seat in the 
abdominal viscera, there are other symptoms of a more palpable 
nature. They principally consist of an uneasiness in the epigastrium 
and a burning sensation in the umbilical region. Flatulence, disordered 
bowels, palpitation of the heart, and flushes of heat in the face occur 
less frequently. Each of these morbid sensations is a source of great 
anxiety to the patient. He watches, studies and bewails them. By- 
and-bye he locates them in a particular organ or a certain part of the 
body, and is convinced that he is the victim of a serious disease. The 
shifting character of these morbid sensations is probably the reason 
why hypochondriacs imagine they are successively affected by a 
variety of diseases. Now it is the stomach, then the liver, next the 
heart, the lungs, the bowels, the bladder or spinal marrow. This 
change in the situation of the fancied disorder is sometimes suggested 
by the names of diseases about which they hear or read, or is prompted 
by an odd and fantastic notion concerning the nature of their troubles. 
Hypochondriacs continually change their medical advisers and are 



HYPOCHONDRIASIS. 161 

voracious consumers of drugs. Many are in fear of losing their 
sexual powers, and if ever they had syphilis, or imagine they had, 
they become the victims of syphilophobia. 

Etiology. Hypochondriasis chiefly affects men, but typical examples 
of the malady are occasionally observed in women. It is always a 
chronic affection, though it rarely endangers life. 

Treatment, Although hypochondriac people are exceedingly fond 
of taking medicines and often declare they are benefited by them, 
yet they never will admit that they are cured. There is no use to 
direct treatment against any special symptom, for ten others will take 
its place. Attention should nevertheless be paid to the digestive organs, 
which are frequently disordered. Vegetable tonics, such as calisaya 
bark, cascarilla, columbo and gentian, with the addition of a mineral 
acid, answer very well. This should be assisted by an occasional pill 
of aloes in combination with mix vomica, or some bitter water, 
when hemorrhoids exist. In fact the torpidity of the bowels is a 
standing complaint of these patients. An active life, devoted to some 
regular occupation which involves considerable physical exertion, is 
often of greater service than all medication. Good results may also 
be obtained from the so-called "moral therapeutics," which consists 
in the effort to wean the patient from his gloomy thoughts and 
brooding over his fancied ailments. According to circumstances he 
may be urged to enter a political career, or take an interest in a 
popular philanthropic cause ; attend to vestry meetings, engage in a 
scientific pursuit, or cultivate one of the fine arts. Extensive 
travelling, which breaks in upon the monotonous routine of life, 
is sometimes beneficial. Strategy has in some instances proved 
successful. 

Griesinger quotes the case of a young woman who fancied that her intestines 
protruded through the oartly-opened abdominal walls. Her physician did not 
dispute her assertion, but remarked that it is not unusual in the event that the 
abdominal muscles are weak for the intestines to come to the surface. He ordered 
an apparatus to support the parts, and he had the satisfaction not only to cure her 
of her false idea, but also relieved the obstinate constipation of the bowels from 
which she had suffered for a long period. 



162 manual of nervous diseases. 

The General Paralysis of the Insane (Paralytic 
Dementia). 

A sad interest attaches to this disease which, in popular language, 
has received the ominous designation of " softening of the brain." It 
attacks men in the prime of life, rapidly destroying in its progressive 
course both body and mind. A singular combination of motor and 
psychical disturbances characterizes the typical form of this affection, 
which is traceable to marked lesions of the brain and its membranes. 

Clinical History. It is convenient to divide the clinical history of 
paralytic dementia into three stages : 1, the premonitory stage ; 2, 
the stage of acute mania; and 3, the stage of chronic dementia and 
muscular prostration. 

The Premonitory Stage. Enfeeblement of the mind and alteration 
of character, habits and inclinations, may for an indefinite period 
constitute the only indications of the disease. The mental defect 
principally manifests itself by forget fulness, a lowered intellectual 
capacity, and oscillation of the will. There is, besides, a laxity of 
moral behavior which is not usual with the patient. He indulges in 
excesses, visits disreputable houses, passes much of his time in low 
drinking shops and spends his money freely. Such a patient can 
hardly be said to be insane, but he certainly is drifting into it. The 
manner in which this moral deterioration displays itself is influenced 
by the social position and pursuits of the patient. If he is a 
merchant or a professional man, he becomes careless of his promises, 
neglects his appointments, mislays important papers, gives orders that 
derange his business and forgets them. The sedate pater familias 
raises scandal by his unbecoming conduct, which he takes little pains 
to conceal or to defend. Another makes expensive presents to 
persons he knows and does not know, or engages in foolish enterprises 
that involve heavy pecuniary losses. The friends and acquaintances 
of such patients are puzzled to account for this change of character. 
During this stage of development symptoms of a different order begin 
to make their appearance. Headache and vertigo are much complained 
of, and fainting fits, due to cerebral congestion, become alarmingly 
frequent. Very commonly, some disturbance of speech is noticeable, 
as if the tongue were too heavy. Words are articulated with 
difficulty, attended by trembling of the upper lips and quivering of 
facial muscles, like in a person who attempts to speak under a great state 



GENERAL PARALYSIS OF THE INSANE. 163 

of excitement. The gait is somewhat stiff and awkward, the pupils 
are unequal and occasionally there is squinting. Gradually a form of 
insanity develops, which is distinguished by delusions of grandeur 
and exaltation. Patients boast of their wealth and distinction, their 
muscular prowess and elevation of spirits. This stage is sometimes 
ushered in by paroxysms of maniacal excitement, usually of short 
duration. Instead of this expansive state of the mind there is 
occasionally witnessed a depressed mental condition of a melancholic 
or a hypochondriac nature; but, invariably, the final stage in all 
cases is that of hopeless dementia. Parallel with the progressive 
obscuration of the intelligence, the extent and intensity of the paretic 
condition steadily increases until the patient is reduced to an utter 
wreck of his former self. He no longer recognizes familiar faces, 
nothing attracts his attention or excites his interest, an unin- 
telligible stutter replaces speech, the muscular weakness renders 
him completely helpless, he cannot walk without the assistance of 
the attendants, and he must be fed, dressed and cleansed like a 
child. Although the appetite is fairly good, and sometimes even 
voracious, still the general nutrition of the body suffers. Paralytics 
may linger on in this miserable condition for a considerable time, 
but many of them are carried off by intercurrent diseases or succumb 
to the frequent recurrence of their convulsive or apoplectiform 
attacks. Death by suffocation is not uncommonly caused from 
morsels of food becoming lodged in the oesophagus, due to paralysis 
of the tongue and pharynx. 

A few of the more important symptoms require special consider- 
ation. 

The delusions of exaltation are not peculiar to general paralysis, 
but they are witnessed in this disease with exceptional frequency, 
and distinguished by their extreme absurdity, which overleaps all 
bounds of the possible. An ordinary maniac may fancy that he 
is a king, a millionnaire, an apostle ; he acts the assumed role and 
maintains his pretensions against all comers; but the demented 
paralytic declares in one breath that he is the king of kings, the 
possessor of millions, Napoleon, the Pope, Bismarck, and a tight-rope 
dancer. He is never struck by the incongruity of these fictions of his 
mind, personates them but indifferently, and can be easily persuaded 
to drop them, though only to take up others just as senseless and 
ridiculous. Even when the delusions betray a melancholic basis 
they partake of the absurd. A patient will say that he only measures 



164 MANUAL OF NERVOUS DISEASES. 

one inch in height, that he is three-cornered, that he was buried 
yesterday. The delusions in the female patient turn more upon 
matters that are congenial to her sex. She boasts of possessing 
innumerable silk dresses, has drawers full of the richest lace 
handkerchiefs, is confined every day with twins, and the like extrava- 
gances. 

The maniacal paroxysms of the demented paralytic are episodical, 
exhibiting sometimes such a violence that patients in their blind, 
imbecile fury attack every one within their reach. They are 
exceedingly troublesome inmates of hospitals ; they are noisy, filthy, 
mischievous and destructive. During the calm intervals, however, 
they are easily controlled if indulgence be shown to their silly but 
harmless fancies. 

Apoplectiform and epileptoid seizures occur at irregular periods 
during the whole course of the disease. The former are distinguished 
from apoplectic attacks resulting from cerebral hemorrhage, by the 
circumstance that the subsequent hemiplegia disappears quickly or 
is hardly perceptible. The convulsive seizures may bear the closest 
resemblance to genuine epilepsy, but more frequently there is no 
complete loss of consciousness, and the spasms are not general. 
Patients usually recover from these attacks, though they constantly 
lose ground after each of them. 

When the paralytic is visited in the insane asylum, to which he 
usually finds his way at some time or another, he can be easily 
recognized by his bloated face and idiotic expression. He is entirely 
oblivious of his wretched condition, and appears contented and 
happy. On being asked how he feels he will complacently answer 
that he never felt stronger and better in his life. He will probably 
regale his visitors with an account of the gold mines he owns, the 
splendid horses and carriages which are at his command, the palatial 
mansion in which he resides, and perhaps present the medical 
attendants and nurses as his servants and lackeys. He is continually 
writing letters to bankers and other people, though he does not 
wonder why he gets no replies. 

Before the last stage of imbecility and paralysis is reached it is 
not very rare to witness repetitions of remarkable improvement of 
all the symptoms. This improvement is sometimes so decided and 
prolonged that the family or friends of the patient are inclined to 
remove him from the hospital, under the impression that complete 
recovery has taken place. Such a patient may again be capable of 



GENERAL PARALYSIS OF THE INSANE. 165 

attending to the ordinary transactions of life and enjoy the liberty and 
comforts of home. It may cause much embarrassment to the alienist, 
when called upon for his opinion whether such a person is competent 
to enter into engagements which involve serious responsibilities. 
Experience has taught that relapses, in cases of this kind, are the rule, 
and that such invalids are liable to break down again whenever they 
attempt the management of complicated affairs. 

Diagnosis. Familiarity with the mode of development and the 
symptomatology of a typical case of paralytic dementia renders the 
diagnosis of this disease comparatively easy. Its distinction from 
allied forms of insanity has already been mentioned. There may 
arise some difficulty in distinguishing the disease from certain cases of 
cerebral syphilis, but the peculiarities of the clinical features of the 
former will help to remove the doubt. 

Prognosis. The average duration of the disease is about three 
years. The prognosis is exceedingly unfavorable. A few cases of 
recovery are on record, but thousands die yearly of this terrible 
disease in our hospitals. 

Etiology. Heredity is one of the special predisposing causes of 
paralytic dementia, but this influence is less marked than in other 
varieties of insanity. It affects persons between the ages of forty 
and fifty-five years, which shows that its development is favored by 
the strains to which the brain is exposed during the most active 
period of life. The greater frequency of the disease in men than in 
women is in the proportion of seven to one. Among the exciting 
causes are mentioned sexual excesses and alcoholism ; it is probable, 
however, that the existence of a constitutional vulnerability of the 
brain offers in these cases a diminished resistance to these morbific 
influences. 

Anatomical Changes. The post-mortem appearances indicate the 
existence of a chronic inflammatory affection, involving the meninges 
and the substance of the brain, and also to some extent the spinal 
cord. This pathological condition is usually limited to the pia mater 
and cortex of the frontal lobes and adjacent regions. The thickness 
of the pia is most marked along the course of the large bloodvessels. 
The dura mater is commonly involved in the morbid process and 
may give rise to hemorrhagic pachymeningitis. Microscopical 
appearances embrace changes of the bloodvessels, dilatation of the 



166 MANUAL OF NERVOUS DISEASES. 

peri-vascular canals and emigration of blood corpuscles. The 
anatomical alterations affecting the brain consist of sclerosis, atrophy 
and degeneration of the nerve elements. Analogous changes are 
occasionally found in the spinal cord. Its membranes in some places 
show the signs of chronic inflammation. The posterior or lateral 
columns may be alone affected. 

Treatment. In the face of the exceeding grave nature of 
general paralysis and its fatal tendency, therapeutic measures 
hold out but the faintest hope to accomplish anything. The 
more urgent is it, therefore, to recognize the disease at its outset, 
not only for the purpose of saving the patient from the debilitating 
influence of the excesses that hasten its development, but also to be 
able at an early date to apprise his family or his friends of the risk he 
runs in effecting his pecuniary ruin, loss of character and reputation. 
Alcoholic stimulants are particularly obnoxious, though at a later 
period they are of service. The potassium iodide should have a fair 
trial. Digitalis is the remedy which stands in highest repute for 
calming the attacks of maniacal excitement. It is given in doses of 
fifteen to thirty minims of the tincture every three or four hours. 
The fluid extract of conium in ten to twenty drop doses is also highly 
recommended. A ferruginous preparation, especially the tincture 
of the chloride of iron, is sometimes of great benefit after the state 
of excitement has abated. The epileptiform seizures must be 
controlled by the bromides. 



INDEX 



Abscess, cerebral, 127. 

ACC (anodic closure contraction), 36. 

iEsthesodic, 6. 

Anaemia, 44. 

" cerebral, 113. 
Aneesthesia, 21. 

" tests of, 22. 

" incomplete, 22. 

cerebral; 23, 117. 
" in myelitis, 80. 

" in loco-motor ataxy, 92. 

Anelectrotonus, 35. 
Angina pectoris, 53. 
AOC (anodic opening contraction), 36. 
Aphasia, 14. 

" in occlusion of cerebral arteries, 
123. 
Apoplexy, cerebral, 116. 

" congestive, 113, 115. 

" in bulbar paralysis, 133. 

" in cerebral embolism and 

thrombosis, 122. 
" in general paralysis of the 
insane, 164. 
Aran, 98. 

Ataxy, in bulbar paralysis, 124. 
" in loco-motor ataxy, 89. 
Athetosis, 29. 
Atrophy, muscular, 87. 

" "in bulbar paralysis, 99. 

" "in loco-motor ataxy, 99. 

" " progressive, 97. 

Axis, cylinder, 1. 

Batteries, 34. 

" care of, 41. 

Beard, Dr., 158. 
Bedsores, 81. 
Blaud's Pills, 154. 
Blepharospasm, 68. 
Borborygmi in hysteria, 151. 
Brain, 9. 

" arterial circulation of the, 17. 



Brain, congestion of the, 112. 

" softening of the, 122. 
Brenner, 37. 
Broca's convolution, 10. 
Brodie, Sir Benjamin, 151. 
Brown-Sequard, 82, 93, 94, 145. 

Cephalic symptoms, 24. 
Cephalalgia (see Headache). 
Cerebellum, 15. 
Charcot, 72, 95, 97, 100. 
Cheyne-Stokes' respiration, 26. 
Chorea, 146. 

" magna, 148. 
Clarke, Lockhard, 84. 
Clarke's column, 4. 
Clavus hystericus, 151. 
Clubfoot, 87. 
Coma, 25. 
Contractures, 30. 

" post hemiplegic, 118. 

Contractions, laws of, 36. 
Convolutions, 10. 
Convulsions, 29. 

" epileptiform, in cerebral 

tumors, 125. 

" hysterical, 152. 

" in paralytic dementia, 164. 

" renal, 144. 

Coordination, 7. 

" center of, 15. 

Corpora quadrigemina, 15. 

" striatum, 15. 
Cortex, 13. 

Cough, hysterical, 151. 
Cramps, 29. 

Crises gastriques, in loco-motor ataxy, 92. 
Crura cerebri, 15. 
Cruveilhier, 98. 

Current, ascending and descending, 39. 
" direction of the, 31. 

faradic, 34. 
" galvanic, 31. 



168 



IN DEX . 



Current, physiological effects of, 36. 

" labile and stabile, 40. 
Cystitis in myelitis, 81. 

Deiter's cells, 95. 

Delirium, 25. 

Density of electric current, 33. 

DeWatteville, 40. 

Dribbling, 84. 

Duchenne, 95, 99, 101, 132. 

Electricity, medical, 31. 

" catalytic action of, 39. 

" dosage of, 40. 

' ' electrolytic action of, 39. 

" practical remarks on, 40. 

Electric bath, 41. 

Electric hand, 42. 

Electro-cutaneous sensibility, 36. 

Electro-diagnosis, 38. 

Electro-muscular contractility, 36, 81. 

Electro-motive force, 31. 

Electrodes, 33. 

Electro-physics, 31. 

Electro-physiology, 35. 

Electrotonus, 35. 

Embolism and thrombosis of the brain 
(see Softening of the Brain). 

Epilepsy, 137. 

Epileptiform convulsions in cerebral 
abscess, 128. 

Epileptiform convulsions in bulbar 
paralysis, 130. 

Epileptiform convulsions in cerebral 
tumors, 125. 

Epileptiform convulsions in general pa- 
ralysis of the insane, 164. 

Epileptiform convulsions in cerebral 
syphilis, 130. 

Erb, 97, 101, 158. 

Fainting fits, 114. 
Faradisation, general, 41. 
Fibrillary twitching of muscles, 100. 
Fissures of the brain, 9. 



Galvanization of the brain, 37. 

" spinal cord, 37. 

" general, 41. 

" of internal organs, 38. 

" of the sympathetic nerve, 37. 
Ganglia, central or basal, 14. 
Genito-urinary center, 8. 
Githens, Dr., 75. 
GolPs column, 4. 
Gowers, Dr., 145. 
Grey degeneration, 84. 

Hammond, 94. 
Headache, 24. 

" in cerebral abscess, 128. 

syphilis, 130. 
tumors, 125. 
" habitual, 56. 

" in meningitis, 104. 

" varieties of, 55. 

Hemorrhage of the meninges, 73, 119. 

" cerebral, 115. 

Hemi-anaesthesia in hysteria, 151. 
Hemicrania, 45. 
Hemiplegia, cerebral, 117. 
infantile, 121. 
" spinal, 86. 

Hot Springs of Arkansas and Virginia, 

83. 
Hughlings, Jackson, 126, 141, 146. 
Hydrocephalus (see Tubercular Menin- 
gitis). 
Hydrocephaloid, 114. 
Hyperemia of the brain, 112. 

" " meninges, 73. 

Hyperesthesia, 21. 

" in hysteria, 151. 

Hypochondriasis, 160. 
Hysteria, 150. 

Incoordination, 89, 90. 
Inflammatory reaction, 117. 
Inhibition, 7. 
Insanity in cerebral syphilis, 131. 

" epileptic, 138. 
Insomnia, 25. 



INDEX 



169 



Katelectrotonus, 35. 

Kinesotic, 6. 

KCC (kathodic closure contraction), 36. 

KOC (kathodic opening contraction), 36. 

Leptomeningitis, 104. 
Leyden, 92, 95. 

Lipomatous hypertrophy of muscles 
(see Pseudo-hypertrophy of Muscles). 

Main en griff e, 99. 
Medulla oblongata, 16. 

" " its automatic and re- 

flex centers, 16. 
" disease of the, 132. 

Meningitis, chronic, 106. 

" epidemic cerebro-spinal, 75. 
" simple cerebral, 103. 

" spinal, 73. 
" syphilitic, 105. 
" tubercular, 107. 
Miliary aneurisms, 115. 
Motor points, 39. 
Myelitis acute, 78. 

" chronic, 82. 
Muscular sense, 2. 

Nerves, afferent and efferent, 1. 
action of the, 19. 
non-medullated, 2. 
of common sensation, 2. 
" special " 2. 

" sympathetic system of, 17. 
Nerve cells, 2. 

'' functions of, 3. 
' ' ganglionic , of the spinal cord , 4 . 
" structural elements of, 2. 
Nerve fibres, 2. 

" course of communication in 
the spinal cord, 4. 
'* "'in the brain, 19. 
" " non-medullated, 1. 
Neuralgia, brachial, 49. 

" complications of , 43. 

diagnosis of, 44. 
' ' dorso-intercostal, 49. 
etiology of, 44. 



Neuralgia, facial, 47. 

" general treatment of, 45. 

" lumbar, 50. 

" occipital, 48. 

" sciatic, 60. 

" in loco-motor ataxy, 91. 
spinal irritation, 156. 
Neurasthenia, 158. 
Neuritis, acute and' chronic, 59. 
Nervousness, 44. 
Nystagmus, 67, 96. 

Oculo-spinal center, 8. 

Ohm's law, 32. 

Optic neuritis in brain tumors, 126. 

Ovarialgia, 151. 

Pachymeningitis, 109. 
Pain, 21. 
Paresthesia, 22. 
Paralysis, 23, 

" acute ascending, 86. 
" agitans, 66. 

alternate, 118, 119. 
Bell's, 60. 
bulbar, 132. 
" cerebral, 24. 
" diphtheric, 58. 
" emotional, 82. 

facial, 60. 
" general paralysis, compli- 
cated with multiple scle- 
rosis, 96. 
" general, of the insane, 61. 
" hysterical, 153. 
" in cerebral syphilis, 130. 
' ' infantile spinal ( see Polyomye- 

litis). 
" ischemic, 58. 
" Kennedy's, 88. 
" labio-glosso pharyngeal, 132. 
" Landry's (see Acute Ascend- 
ing). 
" laryngeal, 63. 
" of multiple sclerosis, 96. 
" of ocular muscles, 58. 



170 



INDEX. 



Paralysis, of the sterno-cleido mastoid 
muscle, 64. 
' ' of the serratus magnus, 65. 
" of the lower extremities, 65. 
" of the upper extremities, 65. 
peripheral, 28, 56, 116. 
reflex, 84. 
" rheumatic, 57. 
" spasmodic spinal, 97. 
" spinal, 27. 
" toxic, 57. 
Paralytic dementia (see General Paral- 
ysis of the Insane). 
Paraplegia, after acute diseases, 85. 
" chronic, 83. 

" hysterical, 84. 

• ' of acute myelitis, 80. 

'• syphilitic, 85. 

Pflueger, 35. 
Polar method, 39. 
Polyomyelitis anterior acute, 86. 
Pons variolii, 15. 

Pseudo-hypertrophy of muscles, 101. 
Ptosis in cerebral syphilis, 130. 

" in lesions of the crura cerebri, 
118. 
Pulvermacher's chain, 72. 
Pupillary changes, 26. 
Pupils, pin's head contraction in pons 
affections, 118. 

Eailway spine, 82. 

Reaction of degeneration, 38, 62, 87. 

Reflex action, 6. 

Reynold Russel, 72. 

Rheophores, 33. 

Rindneish, 95. 

Rolando, Fissure of , 9. 

" gelatinous substance of, 4. 

Sclerosis, lateral (see Spasmodic Spinal 
Paralysis). 
" multiple, of the brain and 
spinal cord, 94. 
Sensory impressions, their rate of trans- 
mission, 2. 
Somnolence, 25. 



Spasms, local, in hysteria, 67. 
" in spinal irritation, 156. 
" of the glottis in hysteria, 151. 
" of the stern o-cleido-mastoid and 
trapezius muscles, 69. 
Speech center, 14. 

" disturbance in general paralysis 

of the insane, 162. 
" disturbance in multiple sclerosis 
of the brain, 96. 
Spinal cord, its structure, 3. 
" "its functions, 5. 

Stille, Prof., 78. 
Sunstroke, 12. 
Syphilis, cerebral, 128. 

Tabes dorsalis (see Loco-motor Ataxy). 
Table of Prof. Erb, 33. 
"Tache cerebral," 26. 
Tendon reflexes, their abolition in loco- 
motor ataxy, 91. 

" " their augmentation, 98. 

Testicle, irritable, 52. 
Thalamus opticus, 15. 
Tic convulsif , 68. 
Torticollis, 65. 
Tremor, 29. 
Tricks, 68. 
Trismus, 67. 
Trophic changes, 8. 

" nerves, 18. 
Trousseau, 113. 
Tuerk, 98. 
Tumors, cerebral, 124. 

Vaso-motor center, 16. 

" " system of nerves, 18. 
Vertigo, 25, 60, 125. 
Vision, disturbances of, 90, 96, 126, 131. 
Voltaic alternatives, 40. 
Vomiting, 26. 

Wasting palsy (see Progressive Muscular 

Atrophy). 
Weir Mitchell, 45, 94, 145, 153. 
Wrist drop, 57. 
Writer's cramp, 57. 



EERATA. 

On page 2, read " Schiff " instead of " Pfluger." 

On page 35, read " direction" instead of " duration" of the current. 



